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RC73  .M1 6  A  clinical  manual;  a 


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A   CLINICAL   MANUAL 


A   GUIDE    TO    THE    PRACTICAL    EXAMINATION 

OF  THE  EXCRETIONS,  SECRETIONS,  AND 

THE     BLOOD,    FOR     THE    USE  OF 

PHYSICIANS  AND  STUDENTS 


BY 


ANDREW    MacFARLANE,   A.B.,   M.D. 

INSTRUCTOR   IN   NEUROLOGY  AND    DISEASES  OF  THE    CHEST  IN  THE  ALBANV    MEDICAL 

COLLEGE,  PHYSICIAN  TO  ST.  PETEr's  HOSPITAL  OUT-PATIENT   DEPARTMENT 

AND   PHYSICIAN   TO  ALBANV's   HOSPITAL   FOR   INCURABLES 


G.  P.  PUTNAM'S    SONS 

NEW   YORK  LONDON 

27   WEST  TWENTY-THIRD    STREET  24    BEDFORD    STREET,    STRAND 

S;^£  ^nitkerbocher  ^ress 
1894 


Copyright,  1894 

BY 

ANDREW   MacFARLANE 


Electrotyped,  Printed  and  Bound  by 

Ube  Iknicfeerbocftcr  press,  IRew  13orfe 
G.  P.  Putnam's  Sons 


PREFACE. 


The  last  decade  has  witnessed  the  most  marvellous 
advances  in  physiological  chemistry,  which,  together 
with  clinical  microscopy,  has  done  much  to  solve  many 
of  the  problems  coming  daily  to  the  attention  of  the 
physician.  To-day  the  physician,  to  be  successful,  must 
be  able  to  use  the  results  of  such  work  in  his  daily 
practice.  This  book  has  been  written  for  the  purpose 
of  giving  in  a  concise  manner  the  methods  employed 
in  such  investigation,  not  so  full  as  to  weary  the  busy 
physician,  but  sufficiently  complete  for  all  practical, 
clinical  purposes.  The  object  is  not  to  make  a  chemist 
or  a  bacteriologist  out  of  the  clinician,  but  to  add  to 
his  practical  knowledge  something  which  would  assist 
him  in  diagnosticating  diseased  conditions.  All  the  pro- 
cedures, with  a  very  few  exceptions,  are  such  as  could  be 
easily  carried  out  by  any  physician  in  his  own  office  with 
a  suitable  microscope  and  a  small  amount  of  apparatus. 

The  writer  has  not  hesitated  to  cull  from  many 
sources,  and  desires  to  acknowledge  his  indebtedness 
to  the  works  of  Jaksch,  Vierordt,  Ewald,  Leube,  Eich- 
horst,  Fraenkel,  Bernheim,  Limbeck,  Rieder,  Lenhartz, 
Halliburton,  Osier,  Councilman  and  Lafieur,  Delafield 
and  Prudden,  and  others,  and  especially  to  Tappeiner's 
Anleitung  zu  Cheftiisch  Diagnostischen  Untersuchimge?!  am 
Krankenbette^  after  which  this  book  has  to  some  extent 

iii 


IV  Preface 

been  modelled,  and  from  which  certain  procedures  have 
been  directly  translated. 

The  writer  also  wishes  to  express  his  thanks  to  Prof. 
T.  Mitchell  Prudden  for  his  kindness  in  allowing  him 
the  use  of  the  laboratory  of  the  College  of  Physicians 
and  Surgeons,  New  York  City,  and  for  his  valuable  sug- 
gestions and  wise  counsel  ;  to  Dr.  Wm.  Halleck  Park, 
who  has  kindly  written  the  section  on  diphtheria,  and 
whose  work  on  that  disease  promises  to  yield  noteworthy 
results  ;  to  Gustavus  Michaelis,  Ph.D.,  who  generously 
gave  considerable  time  to  correcting  the  manuscript  ; 
and  to  several  other  friends  who  have  aided  him  greatly 
with  their  advice. 

Andrew  MacFarlane. 

Albany,  N.  Y. 

April,  1894. 


CONTENTS. 


Part  I.— THE  URINE. 


N 


PAGE 

I. 

— General  Properties  of  the  Urine     .        .        .        .        i 

I  Changes  after  Excretion 

I 

2  Quantity          .... 

2 

3  Color      .         . 

2 

4  Reaction          .... 

3 

5  Specific  Gravity 

5 

6  Quantitative  Composition 

6 

7  Selection  of  a  Specimen 

7 

II. 

— Organic  Substances    .... 

1  Proteids 

8  Albumin          .... 

9  Detection  of  Albumin     . 

10  Estimation  of  Albumin   . 

11  Separation  of  Albumin    . 

12  Fibrin 

13  Nucleo-Albumin  (Mucin) 

14  Albumose        .... 

15  Peptone           .... 

16  Haemoglobin  (Blood  in  the  Urine) 

2  Coloring  Matters         .... 

17  Bile-Pigments          ... 

18  Urobilin          .... 
ig  Indican            .... 

3  Grape  Sugar  (Dextrose) 

20  Glycosuria       .... 

V 

7 

7 

7 

9 

.       13 

.       15 

.       16 

.       16 

.       17 

.       18 

•  19 
.      23 
■       23 

•  25 
.       26 
.       27 
.       27 

VI 


CONTENTS. 


21  Glycuronic  Acid 

22  Acetone 

23  Di-Acetic  Acid 

24  Fat,  Chyle 

25  Urea 

26  Uric  Acid 
III. — Inorganic  Substances 

27  Sulphuretted  Hydrogen 

28  Chlorides 
2g  Sulphates 

30  Phosphates 

31  Carbonates 
IV, — Accidental  Constituents 

32  Mercury 

33  Chlorate  of  Potassium 

34  Iodoform,  Iodine,  Iodides 

35  Bromine  Salts  .... 

36  Carbolic  Acid  .... 

37  Salicylic  Acid,  Salol,  Salicyluric  Acid 

38  Tannin  ...... 

39  Chrysophanic  Acid 

40  Balsam  of  Copaiva 

41  Alkaloids 

V. — Urinary  Deposits 

42  Methods  of  Obtaining  Sediment 
I   Unorganized  Sediment         .  .  .  . 

43  Uric  Acid        ..... 

44  Urates    ...... 

45  Calcium  Oxalate      .... 

46  Di-Calcium  Phosphate    . 
j  47  Ammonio  -  Magnesium    Phosphates  (Tripl 
\  49  Phosphates) 

48  Earthy  Phosphates. 

50  Ammonium  Urates 

51  Calcium  Sulphate    .  ,         «         . 

52  Calcium  Carbonate 

53  Crystalline  Trimagnesium  Phosphate 

54  Cystin 


CONTENTS. 


Vll 


55  Leucin  and  Tyrosin 

56  Hippuric  Acid 

57  Bilirubin 

58  Haemoglobin  . 

59  Fat 
2  Organized  Sediment    . 

60  Mucus    . 

61  Pus 

62  Red  Blood-Cells 

63  Epithelial-Cells 

64  Casts 

65  Spermatozoa  . 

66  Fragments  of  Tumors 

67  Micro-Organisms    . 

68  Chemical  Examination 

69  Micro-Chemical  Examination 
VI. — Urinary  Calculi 

70  Division 

71  Examination 

72  Diagnostic  Table  of  Kidney  Diseases  (Leube) 


PAGE 
60 
61 
61 
61 
61 
62 
62 
62 

63 
63 
65 
67 
67 
67 

68 
68 
69 
69 
70 
73 


Part  II.— THE  STOMACH  CONTENTS. 

1  Digestion    ..... 

2  Examination  of  the  Stomach 

3  To  Estimate  the  Muscular  Power 

4  Removal  of  the  Stomach  Contents 

5  To  Estimate  the  Absorbent  Power 

6  To  Determine  the  Power  of  Secretion 

1  Determination  of  Hydrochloric  Acid 

a  Methyl-Aniline  Violet  Test 
b  Congo-Paper  Test . 
c  Tropaeolin  Paper  Test    . 
d  Phloro-GIucin  Vanilla  Test 
e  Resorcin  Test 

2  Lactic  Acid      .... 

a  Iron-Chloride  Test 

b  Iron-Chloride  and  Carbolic-Acid  1 


est 


75 
75 
75 
76 

77 
78 
79 
79 
80 
80 
8r 
81 
82 
82 
82 


Vlll 


CON  TEN  TS. 


3  Acetic  and  Butyric  Acids  . 

4  Determination  of  the  Total  Acidity 

5  Determination  of  Digestive  Power 

a  Carmine-Fibrin  Test 
b  Egg-Albumin  Test 

6  Rennet-Ferment 

7  Bile    .         .         .         . 

8  Hsemoglobin 

9  Ammonium  Carbonate 
lo  Diagnostic  Table  (Vierordt) 


Part  III.— THE  F^CES. 


1  Bile-Pigment 

2  Albumin 

3  Blood 

4  Crystals 

5  Concretions 

1  Gail-Stones 

2  Intestinal  Stones 


Part  IV.— THE  BLOOD. 


1  General  Properties 

2  Red  Blood-Cells 

3  Thoma-Zeiss  Hsemacytometer     . 

4  Gowers'  Haemoglobinometer 

5  V.  Fleischl's  Hsemometer   . 

6  White  Blood-Cells  (Leucocytes) 

7  Leucocytosis        .... 

1  Forms  of  Leucocytes 

2  Ehrlich's  Division  of  Leucocytes 

8  Examination  of  Blood 

Preparation  of  Cover-Glasses 

9  Staining  Solutions 

Ehrlich's  Stains    . 
lo  Diseases  of  the  Blood 


CONTENTS. 


IX 


Part  v.— PATHOLOGICAL  FLUIDS. 


1  Transudates 

2  Exudates    .... 

3  Contents  of  Ovarian  Cysts  . 

4  Contents  of  Hydronephrosis 

5  Contents  of  Echinococcus  Cysts 


PAGE 

io8 
io8 
log 
III 

112 


Part  VI.— PATHOGENIC  MICRO-ORGANISMS. 


I 

Tuberculosis       .....••• 

114 

Bacillus  Tuberculosis  in  Sputum  .         .         .         • 

114 

Preparation  of  Cover-Glass 

114 

Staining       .....••• 

115 

Bacillus  Tuberculosis  in  Urine      .          .          .          . 

"7 

2 

Gonorrhoea          .         .         .         .  •      . 

117 

Micrococcus  Gonorrhoeae      .... 

117 

3 

Pleurisy      .......•• 

ii8 

Empyema  Due  to  Streptococci      .         .         .         . 

iig 

Empyema  Due  to  Pneumococci    . 

119 

4 

Diphtheria           ....... 

121 

Diphtheria  Bacilli         ..... 

121 

Pseudo-Diphtheria 

T22 

Streptococci  and  Other  Cocci 

122 

The  Methods  Used  to  Determine  the  Presence  o 

123 

Preparation  of  Materials  and  Apparatus 

126 

5 

Amoebic  Dysentery      ....•• 

.      127 

Amoeba  Coli 

.       127 

6 

Malaria 

.       128 

Plasmodium  Malarise 

.       128 

Appendix  I.    .        . 

.       131 

Appendix  II. 

.       133 

Index 

.       135 

LIST  OF  ILLUSTRATIONS. 


FIG. 

1.  Urinometer 

2.  Esbach's  Albuminimeter       .... 
Spectrum  of  Oxyhemoglobin  ^ 

"  "  Meth.^moglobin  ^ 

"  "  Reduced  Haemoglobin  ) 

4.  H^MiN  Crystals 

5.  Phenyl-Glucosazon  (Jaksch)  {see  back  of  vohiuie). 

6.  Saccharometer     .        .        .        ... 

7.  Ureometer 

8.  The  Ltften  Centrifugal  Machine 

9.  Uric-Acid  Crystals 

10.  Calcium-Oxalate  Crystals  .... 

11.  Di-Calcium-Phosphate  Crystals  (Jaksch)  . 

12.  Triple  Phosphates 

13.  Ammonium-Urate  Crystals  .         ... 

14.  Calcium  Sulphate  (Jaksch)  .... 

15.  Calcium  Carbonate  (Jaksch) 

16.  Leucin  and  Tyrosin 

17.  HiPPURic  Acid  (Jaksch)         .        . 

18.  Leucocytes 

19.  Red-Blood  Cells 

20.  Epithelial  Cells 

21.  Casts 

22.  Einhorn's  Stomach  Bucket 

23.  Thoma-Zeiss  H/emacytometer  Capillary  Tube 

24.  Thoma-Zeiss  H/emacytometer  Slide  for  Counting 

25.  Gowers'  Hemoglobinometer       .... 

26.  Von  Fleischl's  H/emometer         .... 


PAGE 

5 

15 

20 

23 
40 

45 
54 
56 
57 
58 
58 
59 
59 
60 
60 
61 
63 
63 
64 
65 
77 
94 
95 
96 
98 


xii  LIS T  OF  ILL  US TRA  TION S. 


27.  Stained  Preparation  of  Normal  Blood  {see  back  of 

volume^. 

28.  Anemic  Blood  Stained  by  Ehrlich's  Method   {see 

back  of  volume). 

29.  Leuk.-^mic  Blood  Stained  with  Eosin  and  H^mo- 

TOXYLON  {see  back  of  volume). 

30.  Arrangement  of  Cover-Glasses  .        .         .        .        .115 

31.  Tubercle  Bacilli  from  Sputum  {see  back  of  volume). 

32.  Micrococcus   Gonorrhce^  (Gonococci)  {see  back  of 

volume). 

33.  Streptococci  (Delafield  and  Prudden)      ,        .        .     119 

34.  Pneumococci  from  a  Case  of  Empyema        .        .        .     120 

35.  Pure  Culture  of  Diphtheria  Bacilli  from  Serum 

Culture  from  Throat 121 

36.  Mixed  Culture  of  Cocci  and  Diphtheria  Bacilli     .     125 

37.  Culture  of  Various  Forms  of  Cocci  and  a  Few  Non- 

Pathogenic  Bacilli 125 

38.  Amceba  Coli  (Delafield  and  Prudden)        .        .        .127 

39.  Plasmodium  Malaria  , 128 


A  CLINICAL   MANUAL. 


Part   I.— THE   URINE. 
I. — General  Properties  of  the  Urine. 

I.  Changes  after  Excretion. — Normal  urine  when 
voided  is  transparent.  It  becomes  slightly  cloudy  after 
standing,  due  to  the  presence  of  mucus  and  epithelium. 
After  a  time  (over  twenty-four  hours)  a  sediment  com- 
posed of  uric  acid,  urates,  and  calcium  oxalate  is  formed, 
if  alkaline  fermentation  has  not  taken  place  within 
that  time. 

Alkaline  fermentation  usually  occurs  in  twenty-four 
hours,  though  it  may  set  in  earlier  or  later  than  this.  It 
appears  most  rapidly  in  faintly  acid  urine,  in  urine  of  low 
specific  gravity,  in  urine  containing  albumin,  blood,  or 
mucus,  and  in  urine  collected  in  dirty  vessels.  The  urine 
becomes  cloudy  and  alkaline  through  the  development 
and  action  of  fungi, ^  which  convert  the  urea  into  am- 
monium carbonate  : 

CH4N2O  +  2  HgO  =  (N  H  J2CO3 

urea  water       ammonium  carbonate 

As  a  result,  a  sediment  composed  of  the  earthy  phos- 
phates, ammonio-magnesium   phosphates,   and    later  of 

*  Principally  of  two  kinds,  micrococcus  ureae  and  bacterium  ureae. 

I 


2  A    CLINICAL  MANUAL. 

ammonium  urates  is  formed.    The  odor  becomes  pungent 
on  account  of  the  volatiUty  of  the  ammonium  carbonate. 

2.  Quantity. — The  quantity  of  urine  voided  by  a 
normal  adult  in  twenty-four  hours  ranges  from  1200- 
1500  c.c.  (40-50  fluid  ounces).  It  is,  however,  very  vari- 
able in  health,  being  complemental  to  the  excretion  by 
the  lungs,  the  skin,  and  the  bowels,  and  increased  or 
diminished  by  an  increase  or  decrease  in  drink  and  food. 

It  may  sink  in  disease  to  nothing,  anuria,  or  be  increased  to  about 
10,000  c.c.  (338  fluid  ounces),  polyuria.  In  general  it  is  in  an  inverse 
ratio  to  the  specific  gravity,  to  the  intensity  of  the  color,  and  to  the 
degree  of  acidity.  Highly  colored,  strongly  acid  urine  has  a  high 
specific  gravity,  but  the  quantity  is  small.  Pale,  faintly  acid  urine 
has  a  low  specific  gravity,  but  the  quantity  is  large.  Pale  urine  of  a 
high  specific  gravity  and  in  increased  quantity  is  indicative  of  diabetes 
mellitus. 

3.  Color. — The  color  of  normal  urine  varies  from  a 
pale  yellow  to  an  amber  yellow  depending  upon  its  degree 
of  concentration  ;  the  more  concentrated,  the  darker  the 
color.  It  may  be  altered  either  by  a  change  in  the  normal 
urinary  pigments  or  by  the  presence  of  abnormal  coloring 
matters. 

1.  The  Urinary  Pigmeiits^  especially  the  urobilin,  are 
increased  : 

relatively,  by  concentration  of  the  urine  ; 

absolutely,  by  increased  tissue  metamorphosis,  fever,  and  hemor- 
rhage, when  the  hsemoglobin  is  converted  into  urobilin. 

They  are  decreased  by  a^n  increased  .proportion  of  water  and  in 
anaemia. 

Pale  urine,  not  increased  in  quantity,  appears  in  convalescence  after 
fevers. 

2.  Abnormal  Coloring;  Matter, 


THE  URINE.  .3 

(a)  Those  which  normally  exist  in  the  organism  but 
appear  in  the  urine  as  a  result  of  pathological  changes. 

1.  The  pigment  of  the  blood — bright  red  to  brownish  black. 

2.  The  pigment  of  the  bile — yellowish  green  to  brownish  yellow. 

3.  Melanin  (seldom) — brown  to  black. 

The  urine  when  excreted  usually  contains  only  melanogen  and  from 
this  the  pigment  (melanin)  is  formed  gradually  by  exposure  to  the 
air  or  rapidly  by  the  action  of  an  oxidizing  agent. 

(b)  Color  following  the  use  of  drugs  or  certain  foods. 

1.  After  the  administration  of  carbolic  acid,  tar,  leaves  of  uvaursa, 
and  similar  drugs,  sulpho-acids  and  aromatic  phenols  are  formed. 
These  are  colorless  in  themselves,  but  are  easily  oxidized  and  converted 
into  greenish-black  products  as  soon  as  the  urine  becomes  alkaline 
(carboluria). 

2.  After  the  ingestion  of  rhubarb  or  senna,  chrysophanic  acid 
appears  in  the  urine.  The  urine  does  not  change  in  color  while  acid, 
but  assumes  a  brown  to  blood-red  color  when  alkaline. 

3.  After  the  administration  of  santonin  the  urine  has  a  saffron  to 
green  color,  resembling  icteric  urine.  The  addition  of  caustic  soda 
to  such  urine  produces  a  red  color  similar  to  that  due  to  the  use  of 
rhubarb  or  senna  (this  differentiates  it  from  biliary  coloring  mater). 

4.  Reaction. — Normal  urine  is  acid,  colors  blue  litmus 
paper  red,  due  not  to  the  free  acids  but  to  the  acid  salts, 

especially    mono-sodium    phosphate   NaHgPO^      (acid 
sodium  phosphate). 

It  may  however  be  2Xk.2X\XiQ,  colors  red  litmus  paper  blue, 
due  to  : 

(a)  The  presence  of  the  so-called  fixed  alkalies,  i.e.,  the  non-volatile, 
alkaline  phosphates  and  carbonates,  viz.  :  di-sodium  phosphate  Na^- 
HPO4,  tri-sodium  phosphate  Na3P04,  and  sometimes  sodium  car- 
bonate NagCOg.  Such  urine  when  excreted  may  be  clear  or  cloudy, 
but  after  a  short  time  it  always  becomes  cloudy  on  account  of  the 
precipitation  of  the  earthy  phosphates  Ca3(P04)2  and  Mg3(P04)3 
with  which  some  crystals  of  ammonio-magnesium  phosphate  may  be 
mixed. 


4  ^    CLINICAL  MANUAL. 

The  alkaline  reaction  of  the  litmus  paper  (change  of  color) 
does  not  disappear  by  drying  the  paper  in  the  air. 

(b)  The  presence  of  ammonium  carbonate. 

Such  urine  has  undergone  alkaline  fermentation  in  the  bladder  and 
is  in  the  same  condition  as  urine  which  has  undergone  fermentation 
outside  of  the  body. 

It  is  cloudy  from  the  presence  of  bacteria  and  of  precipitated  earthy 
phosphates  with  which  many  crystals  of  ammonio-magnesium  phos- 
phate are  mixed. 

The  alkaline  reaction  of  the  litmus  paper  disappears  upon 
drying  the  paper  in  the  air  (due  to  the  volatilization  of  the 
ammonium  carbonate). 

Urine  at  the  beginning  of  alkaline  fermentation  may- 
give  both  reactions,  colors  blue  litmus  paper  red  and  red 
litmus  paper  blue,  caused  principally  by  the  presence,  at 
the  same  time,  of  mono-sodium  phosphate  NaHgPO^^ 
and  di-sodium  phosphate  NagHPO^,  the  former  giving 
an  acid,  the  latter  an  alkaline  reaction. 

Causes  for  the  fluctuation  in  the  reaction  of 

THE  urine  in  normal  AND  PATHOLOGICAL  CASES. 

(c)  The  acidity  of  the  urine  is  increased  ; 

1.  "When  the  urine  is  concentrated,  i.e.,  increased  excretion  of 
water  by  other  channels  than  the  kidneys,  diminished  consumption  of 
fluids. 

2,  Increased  metamorphosis  of  albumin  (meat  diet,  self-consump- 
tion in  fever). 

(d)  The  acidity  of  the  urine  is   lessened  or  entirely 

disappears  : 

1.  Increased  consumption  of  fluids. 

2.  Decreased  metamorphosis  of  tissue  (anaemia,  debility). 

3.  Consumption  of  carbonates  and  alkalies  of  organic  acids 
(citrates,  malates,  tartrates)  which  are  converted  into  carbonates 
and  pass  into  the  urine  (vegetable  diet,  sour  wines,  medicines, 
mineral  waters). 

4.  Removal  of  acids  from  the  blood  by  the  secretion  of  the  gastric 
juice,  transitory  at  every  meal,  but  permanent  by  continuous  vomiting. 


THE  URINE. 


5 


5.  Rapid  resorption  of  alkaline  transudates  and  exudates. 

6.  Alkaline  secretions   in  the  urinary  tract  (cystitis,   gonorrhoea, 
abscess,  etc.). 

7.  Alkaline  fermentation. 

5.  Specific  Gravity. — The  specific  gravity 
of  normal  urine  ranges  from  1015-1025,  the 
specific  gravity  of  water  being  1000.  The 
pathological  variations  fluctuate  from  1002- 
1040. 

The  specific  gravity  of  a  given  portion  of  urine  is  a 
relative  measure  of  the  concentration  of  the  urine.  The 
amount-  of  the  solid  constituents  of  the  urine  can  be 
approximately  estimated  from  the  specific  gravity  of  a 
mixture  of  the  urine  for  the  day,  twenty-four  hours, 
if  the  quantity  of  urine  passed  is  known.  Multiply  the 
last  two  figures  of  the  specific  gravity  by  2  (Trapp's 
coefficient)  or  2.33  (Haser's  coefficient).  The  product 
is  the  weight  of  the  solid  constituents  in  34  fluid  ounces 
(1000  CO.)  of  the  urine  in  grams  (i  gram  =  15.4 grains). 

Method  of  Determination.  This  is 
determined  by  the  urinometer  (Fig.  i)  in 
the  following  manner  :  Fill  the  glass  cylin-  '^^nometer^^" 
der,  usually  sold  with  the  urinometer,  three 
quarters  full  of  urine,  which,  if  necessary,  should  first 
be  filtered.  The  cylinder  should  be  held  inclined  while 
it  is  being  filled  with  urine  to  prevent  the  formation 
of  foam.  The  urinometer,  clean  and  dry,  is  slowly  intro- 
duced so  that  the  instrument  swims  entirely  free  in  the 
urine.  To  determine  accurately  the  specific  gravity, 
bring  the  eye  on  a  level  with  the  lower  border  of  the 
surface  of  the  urine,  and  read  off  where  it  cuts  the  scale 
of  the  urinometer.  This  is  accomplished  as  soon  as  the 
back  border  of  the  surface  of  the  urine  is  no  longer  seen. 

A  dirty  or  wet  instrument  or  solid  particles  suspended  in  the  urine 
cause  the  specific  gravity  to  appear  too  high. 


6  A    CLINICAL  MANUAL. 

A  sensitive  urinometer  should  permit  correct  reading  to  a  half 
degree  and  have  a  scale  extending  from  looo,  the  weight  of  distilled 
water,  to  1060.  The  urinometer  gives  exact  results  only  at  the  tem- 
perature for  which  it  has  been  constructed  (usually  60°  F.).  The 
urine  should  have  this  temperature  when  an  accurate  determination 
is  desired.  For  general  practice,  however,  it  is  sufficient  if  the  urine 
has  nearly  this  temperature,  i.  e.,  the  temperature  of  the  room. 
Warm  urine  has  a  lower,  cold  urine  a  higher  specific  gravity,  a  dif- 
ference in  temperature  of  7°  F.  corresponding  to  one  degree  of  the 
urinometer. 

If  the  quantity  of  urine  is  not  sufficient,  it  may  be  diluted  with  one, 
two,  or  more  volumes  of  water.  The  specific  gravity  of  the  urine 
can  then  be  easily  determined  by  multiplying  the  last  two  figures  of 
the  specific  gravity  of  the  mixture  by  the  total  number  of  volumes  in 
the  mixture.  Thus  if  three  times  as  much  water  as  urine  have  been 
added,  and  the  specific  gravity  of  the  mixture  is  1005,  that  of  the 
urine  is  (05  x  4  =  20)  1020. 

6.  Quantitative  Composition  of  the  Urine. — The 
quantities  of  the  urinary  constituents  excreted  in  twenty- 
four  hours  by  an  average  man  weighing  145  lbs.  (Parkes). 

Grams.  Grains. 

Water 1500.  23,150. 

Total  Solids 72.  i,iii. 

Urea 33.i8  512. 

Uric  Acid .55  8.5 

Hippuric  Acid .40  6.17 

Creatinin .91  14. 

Pigment  and   other  or- 
ganic substances  ....  10.  154. 

Sulphuric  Acid 2. 01  31. 

Phosphoric  Acid 3.16  48.76 

Chlorine 7.00-8.00        108. -123. 45 

Ammonia .77  11.88 

Potassium 2.50  38.58 

Sodium 11.09  171. 12 

Calcium 0.26  4.01 

Magnesium 0.21  3.24 


THE    URINE.  7 

7.  The  Selection  of  a  Specimen  of  Urine. — As 
the  properties  of  the  urine  vary  during  the  twenty-four 
hours,  exact  analysis  requires  that  the  specimen  for 
examination  should  be  a  part  of  the  whole  quantity 
passed  during  that  time  ;  when  this  is  not  convenient 
the  urine  passed  before  breakfast  is  most  suitable.  If, 
however,  traces  of  albumin  are  suspected,  urine  passed 
during  the  day,  and  especially  after  vigorous  physical 
exertion,  contains  more  albumin  than  urine  passed  after 
the  body  has  been  resting. 


II. — Organic  Substances. 

I.— PROTEIDS. 

8.  Albumin. — Albumin  is  a  proteid  substance,  the 
chief  constituent  of  the  body,  and  occurs  as  serum- 
albumin,  serum-globulin,  muscle-albumin,  fibrinogen, 
myosin,  and  the  compounds,  acid  and  alkaline  albumi- 
nates. The  albumin  found  in  albuminuria  consists 
usually  of  serum-albumin  and  serum-globulin,  of  which 
the  serum-albumin  is  generally  in  much  greater  quantity. 

Traces  of  albumin  are  at  times  found  in  the  urine  of 
healthy  individuals,  especially  after  vigorous  muscular 
exertion,  emotional  excitement,  and  digestive  disorders, 
while  careful  microscopic  examinations  show  nothing, 
and  the  clinical  symptoms  of  an  acute  or  chronic 
disease  of  the  kidneys  are  absent  {^physiological  albu- 
minuria). A  continuous  excretion,  however,  of  even  the 
smallest  quantity  is  always  pathological.  Albuminuria  may 
be  the  result  of  an  admixture  of  albuminous  fluids  as 
blood,  pus,  chyle,  though  the   urine  itself  is  free  from 


8  A    CLINICAL  MANUAL. 

albumin.  In  such  cases  the  urine  usually  contains  only 
a  small  quantity  of  albumin,  and  invariably  a  sediment 
of  elements  characteristic  of  the  fluid,  as  blood  cells, 
pus  cells,  etc.  {accidental  albuminuria^.  It  may  also  be 
due  to  the  pressure  of  tumors  or  the  pregnant  uterus  on 
the  renal  vein,  and  may  occur  in  febrile  conditions, 
nervous  disorders  (delirium  tremens,  epilepsy,  concus- 
sion of  the  brain),  in  many  constitutional  diseases,  and 
in  diseases  of  the  blood  (transitojy  albuminuria).  In 
contradistinction  to  these  forms  of  albuminuria  is  the 
renal  albuminuria  due  to  parenchymatous  changes  in 
the  kidney  or  to  circulatory  derangements,  and  charac- 
terized by  the  formation  of  an  organized  sediment  in 
greater  or  less  amounts  (casts,  renal  epithelia,  blood 
cells,  etc.).  It  is  impossible  to  distinguish  the  various 
forms  of  albuminuria  by  chemical  analysis,  as  the  albu- 
min in  all  cases  has  the  same  chemical  character. 
This  problem  must  be  solved  by  the  microscopical 
examination  of  the  sediment.  A  diagnosis  of  renal  dis- 
ease should  therefore  never  be  made  from  albuminuria  alone. 
The  quantity  of  albumin  in  albuminous  urine  ranges 
from  o.i-i.o  per  cent,  or  1-15  grams  (15-231  grains) 
in  twenty-four  hours.  Larger  quantities  of  albumin  up 
to  30  grms  (462  grains)  are  seldom  found.  But  the 
smallest  quantity  is  of  diagnostic  importance. 

Urine  containing  albumin  is  usually  frothy  and  often  cloudy 
from  the  presence  of  bacteria  or  sediment.  If  the  urine  cannot  be 
clarified  by  filtration,  it  should  be  shaken  with  calcined  magnesia  or 
a  few  drops  of  caustic  soda  should  be  added.  A  precipitate  of 
magnesium  or  earthy  phosphates  results,  and  this  takes  up  the 
cloudiness.  This  is  usually  unnecessary  in  ordinary  examinations, 
as  the  tests  employed  for  the  detection  of  albumin  will  cause  almost 
all   the    cloudiness   due    to    unorganized    sediment     to    disappear. 


THE   UklNE.  9 

Cloudiness  the  result  of  organized  sediment  alone  remains.  It 
should  always  be  determined  if  the  urine  to  be  examined  is  free 
from  admixture  with  elements  which  may  contain  albumin  (menstrual 
blood,  faeces,  sputa,  semen,  etc). 

9.  The  Following  Tests  Are  the  Most  Useful 
IN  Determining  the  Presence  of  Albumin. 

I.  Heat  Test. — Boil  the  top  of  a  column  of  urine  in  a 
test-tube  and  add,  if  a  precipitate  forms  or  not,  concen- 
trated nitric  acid  (5-10  drops)  until  the  urine  has  a 
strongly  acid  reaction.  If  the  precipitate  does  not  dis- 
solve, or  forms  after  the  addition  of  nitric  acid,  it  is  due 
to  albumin. 

If  albumin  is  present  in  small  quantity,  a  turbidity  appears  ;  if 
about  .1  per  cent,  is  present,  a  flaky  precipitate  forms,  and  if  there 
is  a  very  high  percentage  of  albumin  (3  per  cent.)  all  the  urine  is 
converted  into  a  solid  mass.  Too  small  a  quantity  of  nitric  acid 
may  not  precipitate  albumin,  especially  if  the  urine  is  alkaline. 
Too  great  a  quantity  may  redissolve  the  precipitate  of  albumin, 
particularly  if  the  urine  is  again  heated  after  the  addition  of  the 
nitric  acid,  or  if  the  nitric  acid  is  added  before  the  urine  is  boiled. 

The  effervescence  after  the  addition  of  the  acid  is  caused  by  the 
elimination  of  carbonic  acid  gas  from  the  carbonates  and  often  occurs 
in  alkaline  urine. 

Reasons  for  the  addition  of  nitric  acid. 

(a)  Albumin,  though  present  in  urine,  may  not  be 
coagulated  by  heat.  This  is  a  common  occurrence  in 
alkaline  urine  even  when  containing  a  moderate  quantity 
of  albumin.  The  albumin  in  such  cases  is  converted 
into  an  alkaline  albuminate  which  is  not  coagulated  by 
heat  but  by  nitric  acid. 

(b)  Urine  when  heated  may  show  a  precipitate, 
although  no  albumin  is  present — earthy  phosphates 
soluble   in   nitric    acid. 


10  A    CLINICAL  MANUAL. 

Urine,  faintly  acid  or  slightly  alkaline,  holds  in  solution  calcium 
and  magnesium  phosphates  as  di-phosphates.  These  are  split  up  by 
heat  into  soluble  mono-phosphates  and  insoluble  tri-phosphates, 
which  form  a  flaky  precipitate  resembling  albumin. 

4CaHP04  =         Ca(H2P04)2         +         C^^{VO^)^ 

Di-calcium  phosphate         Mono-calcium  phos.  Tri-calcium  phos. 

4MgHP0,  =         Mg(H2PO,)3         +         MgaCPO^)^ 

Di-magnesium  phosphate    Mono-magnesium  phos.     Tri-mag.  phos. 

As  the  triple  phosphates  are  very  soluble  in  acids,  they  are  dis- 
solved by  nitric  acid  and  cannot  be  confounded  with  albumin. 

A  similar  precipitation  follows  when  the  urine  holds  hydrocalcium 
and  hydromagnesium  carbonate  Ca  (CO  311)2,  Mg  (CO 311)2,  in  solu- 
tion as  occurs  with  vegetarians.  They  are  converted  by  heat  into 
insoluble  neutral  carbonates  CaCOg,  MgCOg,  and  carbon  dioxide 
CO 3.     These  precipitates  are  also  very  soluble  in  acids. 

Possible  source  of  error. — The  formation  of  a 
precipitate,  not  albumin,  is  limited  to  the  precipitation 
of  resinous  acids  which  appear  in  the  urine  after  the 
administration  of  large  quantities  of  the  balsams,  as 
urates  and  uric  acid  are  very  soluble  upon  the  applica- 
tion of  heat.  If  resinous  acids  are  suspected,  add  two 
volumes  of  alcohol,  which  will  dissolve  resinous  acids 
but  not  albumin.  The  alcohol  should  be  added  only 
when  the  urine  is  cold  and  does  not  contain  more  nitric 
acid  than  recommended,  as  otherwise  the  alcohol  will 
be  oxidized  with  a  stormy  effervescence. 

2.  Nitric  Acid  Test  ( Heller  s  Ring  Test). — Pour  care- 
fully with  a  pipette  into  a  test-tube  containing  concen- 
trated nitric  acid  an*  equal  quantity  of  urine,  holding 
the  test-tube  as  obliquely  as  possible,  so  that  the  fluids 
do  not  mix.  If  at  the  junction  of  the  fluids  a  sharply 
limited  white  cloudiness  in  the  shape  of  a  ring  appears 
immediately  or  after  a  few  minutes,  albumin  is  present. 


THE    URINE.  II 

Possible  Sources  of  Error. — (a)  Precipitation  of 
nitrate  of  urea  (large  crystals).  This  occurs  only  in 
very  concentrated  urine  and  appears  after  some  time. 
Previous  dilution  of  the  urine  prevents  it. 

(b)  Precipitation  of  acid  urates  (cloudiness  in  the 
shape  of  a  ring  somewhat  above  the  junction  of  the 
fluids).  This  also  happens  only  in  concentrated  urine. 
The  uric  acid  is  freed  from  its  salts  by  the  nitric  acid 
and  is  in  part  precipitated  as  it  is  almost  insoluble  in  cold 
water.  This  can  be  avoided  by  diluting  the  urine  with  1-2 
volumes  of  water.  This  ring  is  dissipated  on  the  applica- 
tion of  heat. 

(c)  Precipitation  of  resinous  acids  (ring-shaped  cloudi- 
ness). They  appear  in  urine  as  salts  after  large  doses  of 
balsam  of  copaiva,  styrax,  and  turpentine,  and  are  pre- 
cipitated by  nitric  acid.  Differentiate  this  from  albumin 
by  Test  i  or  4. 

(d)  Precipitation  of  albumose  (an  uncommon  occur- 
rence).     Vide  albumose. 

(e)  Colored  Rings.  The  pigment  of  the  urine  is  ox- 
idized by  the  nitric  acid.  Every  specimen  of  urine 
therefore,  and  especially  the  highly  colored,  will  show  at 
the  junction  of  the  urine  and  nitric  acid  a  brownish-red 
ring  ;  if  indican  is  present,  a  violet  ring  ;  if  bile  pigment, 
Gmelin's  reaction.  All  these  rings  can  be  easily  dis- 
tinguished from  albumin  by  the  absence  of  cloudiness. 

3.  Acetic  Acid  mid  Ferrocyanide  of  Potassium  Test. — 
The  urine  is  rendered  strongly  acid  with  acetic  acid 
(5  drops)  and  1-3  drops  of  a  ten-per-cent.  solution  of 
ferrocyanide  of  potassium  are  added.  If  albumin  is 
present,  a  turbidity  or  flaky  precipitate  appears. 

This  test  is  the  most  delicate  of  all,  especially  when  made  in  the 
same  manner  as  the  preceding  test,  i.  e.,  a  mixture  consisting  of  a 


12  A    CLINICAL  MANUAL. 

drachm  or  two  of  diluted  acetic  acid  and  a  few  drops  of  ferrocyanide 
of  potassium  is  carefully  poured  with  a  pipette  upon  the  urine  in  a 
test-tube.  If  the  slightest  trace  of  albumin  is  present,  a  white  ring 
forms  at  the  junction  of  the  liquids. 

Mistakes  are  possible  by  the  precipitation  of  mucin,  resinous  acid, 
and  uric  acid  on  the  addition  of  the  acid.  The  possibility  of  the 
reaction  of  the  first  two  can  be  eliminated  as  in  the  following  test  and 
that  of  uric  acid  by  diluting  the  urine  with  one  or  two  volumes  of 
water  before  testing.  When  the  quantity  of  albumin  is  very  small, 
the  precipitate  appears  after  a  few  minutes.  If  the  urine  is  highly 
concentrated,  the  precipitate  often  does  not  appear  until  the  urine 
has  been  diluted  with  an  equal  volume  of  water  as  it  is  somewhat 
soluble  in  a  strongly  acid  solution. 

4.  Acetic  Acid,  Sodium  Chloride,  and  Heat  Test. — 
Acidulate  strongly  the  urine  with  acetic  acid  (5  drops), 
add  at  least  \  volume  of  a  saturated  solution  of  sodium 
chloride  and  boil  the  mixture. 

If  a  precipitate  forms  first  during  the  boiling,  albumin 
is  present. 

If  a  precipitate  appears  on  the  addition  of  acetic  acid 
it  may  be  due  to : 

(a)  Uric  acid  freed  from  its  salts  by  acetic  acid  and 
precipitated  in  concentrated  urine.  The  precipitate  is 
redissolved  by  heat  owing  to  its  great  solubility  and  is 
formed  again  so  slowly,  as  acetic  acid  is  a  weak  acid, 
that  it  is  not  usually  observed. 

(b)  Resinous  acids  precipitated  from  their  salts  by  the 
acid.  The  precipitate  when  heated  does  not  disappear, 
in  fact  it  may  be  more  pronounced  as  the  chemical  action 
of  acetic  acid  is  intensified  by  heating.  It  can,  however, 
be  easily  distinguished  from  albumin  by  the  addition  of 
alcohol  after  the  urine  becomes  cold. 

(c)  Mucin.  The  precipitate  does  not  form  when 
sodium  chloride  is  added  first  and  then  the  acetic  acid. 


TBE    URINE.  13 

This  test  has  these  advantages  :  the  color  of  the  urine  is  not 
changed,  the  albumin  is  precipitated  in  heavier  flakes,  and  the  filtrate 
can  be  used  for  other  tests,  e.  g.,  sugar.  Larger  quantities  of  sodium 
chloride  than  \  volume  often  precipitate  the  albumin  before  the  urine 
is  heated,  as  albumin  in  a  concentrated  solution  of  sodium  chloride 
is  rapidly  converted  into  an  acid  albumin  which  is  precipitated  by 
acetic  acid  and  sodium  chloride. 

10.  Quantitative  Estimation  of  Albumin. — 
Exact  quantitative  estimation  is  possible  by  weighing 
the  coagulated  albumin  separated  by  filtration,  or  by 
measuring  the  deflection  to  the  left  of  the  polarization 
line  in  urine  containing  albumin.  The  latter  method 
gives  exact  results  only  for  urine  containing  more  than 
.5  per  cent,  of  albumin  and  is  rendered  difficult  by 
turbidity  and  high  color  of  the  urine,  and  the  former 
requires  more  time  than  the  general  practitioner  can  give. 

An  approximate  estimation,  which  can  be  easily  made, 
is  sufficiently  accurate  for  practical  purposes. 

1,  Heat  and  Nitric  Acid. — The  simplest  method  is  to  boil  a 
quantity  of  urine  in  a  test-tube,  add  a  few  drops  of  nitric  acid,  and 
set  aside  for  12  hours.  If  a  small  quantity  of  albumin  is  present,  a 
turbidity  results  ;  if  about  one  tenth  per  cent.,  a  flaky  precipitate 
forms,  which,  after  settling,  fills  the  curved  bottom  of  the  test-tube  ; 
if  about  one  per  cent.,  the  precipitate  in  bulk  makes  up  about  one 
half  of  the  volume  of  urine,  and  if  the  percentage  of  albumin  is  very 
high  (3  per  cent.),  the  urine  is  converted  into  a  solid  mass. 

2.  Brandberg^s  Method. — This  method  is  based  upon  the  fact 
that  Test  2  (Heller's  ring  test)  shows  the  reaction  for  albumin  the 
more  quickly,  the  richer  the  urine  is  in  albumin.  If  there  is  only  one 
part  of  albumin  in  30,000  of  urine,  the  turbidity  appears  in  2\  to  3 
minutes. 

If  urine  contains  an  unknown  quantity  of  albumin,  it  can  be  easily 
determined,  sufficiently  exactly  for  clinical  purposes,  by  diluting  the 
urine  with  a  known  quantity  of  water  until  the  reaction  ensues  in  i\ 
to  3  minutes.    This  diluted  urine  contains  .0033  per  cent,  of  albumin, 


14 


A    CLINICAL   MANUAL. 


and  from  this  the  per  cent,   of  albumin  in  the  undiluted  urine  is 
quickly  calculated. 

Procedure. -^Concentrated  nitric  acid  is  carefully  poured  with  a 
pipette,  so  that  the  acid  does  not  touch  the  sides  of  the  tubes,  into 
four  test-tubes.  Equal  volumes  of  urine  of  different  degrees  of  dilu- 
tion are  gently  placed  with  a  pipette  upon  the  nitric  acid,  a  different 
dilution  in  each  test-tube,  and  the  time  is  noted  before  a  visible 
bluish-white  ring  appears  in  each  test-tube.  If  the  reaction  occurs 
in  2\  to  3  minutes  in  one  of  them,  this  dilution  of  the  urine  contains 
.0033  per  cent,  of  albumin.  The  quantity  of  albumin  is  then  quickly 
ascertained  from  the  following  table. 

Per  cent,  of  albumin 

in      the     undiluted 

urine  when  the  ring 

appears  after  2^  to 

3  minutes. 

*io  times  =   i  part   urine,    9    parts   water     .         .  0.033 

(10  per  cent,  solution  of  urine  used  for 

the  other  dilutions.) 

part  of  above   dilution    +      i  part  water  =  0.067 


Dilution  of 
the  urine. 


20 

times 

=: 

*3o 

= 

50 

= 

80 

= 

100 

= 

*i5o 

= 

200 

= 

*3oo 

= 

400 

= 

500 

= 

+ 

2 

=  O.IOO 

+ 

4 

=:  0.167 

+ 

7 

=  0.267 

+ 

9 

=  0.333 

+ 

14 

=  0.500 

+ 

19 

=  0.667 

+ 

29 

=  1. 000 

+ 

39 

=  1-333 

+ 

49 

=  1.667 

It  is  well  not  to  make  all  the  dilutions,  but  first  to  test  those  dilu- 
tions marked  with  an  asterisk,  and  thus  determine  if  the  quantity  of 
albumin  is  more  or  less  than  -^^  or  |-  or  i  per  cent.  Then  to  estimate 
exactly,  it  is  only  necessary  to  examine  the  dilutions  between  the  limits 
determined. 

The  first  dilution  can  be  easily  made  by  adding  5  parts  of  urine 
measured  in  a  pipette  to  45  of  water  ;  the  others  are  readily  prepared 
from  this. 

3.  Esbach^s  Method. — The  measurement  of  the  quantity  of  pre- 
cipitated albumin  in  an  especially  constructed  test-tube  (albumini- 
meter). 


THE    URINE. 


15 


Reagent. — A  solution  of  picric  acid  10  grams  (154  grains),  and 
pure  citric  acid  20  grams  (308  grains),  in  a  litre  (33-8  ounces)  of 
water.  This  precipitates  all  the  albumin  except  in  some  very  rare 
cases  which  have  not  yet  been  explained.  It  also  precipitates 
kreatinin,  uric  acid,  and  alkaloids,  but  this  seldom  makes  any 
practical  difference. 

Procedure. — Fill  the  tube  (Figure  2)  up  to  the  mark  U 
with  urine,  which  should  be  fresh  and  acid,  and  add  the 
reagent  to  the  mark  R.  Close  the  tube  with  the  thumb 
and  mix  the  contents  carefully,  inverting  it  several  times, 
so  that  no  foam  is  formed.  Cork  the  tube  and  place  it 
aside  upright  for  24  hours.  The  albumin  gradually  sinks 
to  the  bottom  and  in  24  hours  the  quantity  can  be  deter- 
mined by  the  scale  of  the  albuminimeter  marked  from 
1-7.  These  figures  indicate  the  quantity  of  albumin  in 
grams  in  a  litre  of  urine  or  the  decimal  percentage  of 
albumin.  When  the  urine  is  very  rich  in  albumin  it  should 
be  diluted  with  one  or  two  volumes  of  water  and  the 
result  multiplied  by  two  or  three.  The  Esbach  method 
gives  exact  results  for  a  quantity  of  albumin  as  small  as 
0.1  per  cent,  and  on  account  of  its  simplicity  answers  suf- 
ficiently well  for  all  ordinary  requirements. 

II.    Separation    of  the    Albumin. — It   is       ^"ssr- 

necessary  for  many  of  the  other  examinations  fig.  2. — 

to  separate  the  albumin  present  from  the  urine,  ^sbach  s 
^  ^  Albumin- 

This    is    easily    accomplished   even    when    the    imeter. 

quantity  is  unimportant,  by  heating  the  urine 

rendered  moderately  acid  and  filtering. 

The  urine  when  acid  (neutral  or  alkaline  urine  is  first 

weakly  acidulated  with  diluted  acetic  acid)  should  be 

heated  to  the  boiling  point  and  then  removed  from  the 

flame.     If   a    heavy    precipitate    of    albumin    does    not 

immediately  form,  but  simply   a  cloudiness  appears,  as 

is  usually  the  case,  a  few  drops  of  diluted  acetic  acid 

should  be  carefully  added  until  a  flaky  precipitate  re- 


l6  A    CLINICAL  MANUAL. 

suits.  The  fluid  should  be  again  heated  for  a  moment 
and  at  once  filtered.  Complete  coagulation  is  accom- 
plished when  the  albumin  is  precipitated  in  large  flakes 
and  the  fluid  above  is  clear  and  runs  quickly  through 
the  filter.  When  turbid,  too  little  or  too  much  acetic 
acid  has  been  added.  The  first  is  easily  corrected,  and 
the  second  can  be  by  neutralizing  the  excess  of  acid  by 
the  careful  addition  of  a  diluted  solution  of  soda.  It  is 
easier,  however,  to  re-examine  a  fresh  specimen  of  urine. 

If  urine  or  other  liquids  contain  a  large  quantity  of  albumin,  the 
following  modification  is  valuable  :  Boil  20-30  c.  c.  (one  ounce)  of 
water  in  a  small  porcelain  dish,  add  slowly,  keeping  the  mixture  at 
boiling  point,  one  half  to  one  volume  of  urine  and  stir  continuously. 
The  reaction  is  ascertained,  and  if  necessary  acetic  acid  is  added 
until  it  is  faintly  acid.  A  large  flaky  precipitate  forms  and  is  imme- 
diately filtered. 

The  precipitation  of  albumin  by  acetic  acid  is  often  used  as  a 
test  for  albumin,  but  it  is  not  suitable  unless  very  carefully  employed. 
Too  much  acetic  acid  may  dissolve  a  large  part  of  the  albumin, 
and  even  all  if  merely  traces  of  albumin  are  present. 

12.  Fibrin. — Fibrin  is  found  in  cases  of  hsematuria 
and,  chyluria  and  occasionally  as  a  result  of  irritation  of 
the  kidneys  after  the  use  of  cantharides  and  of  an 
inflammatory  exudation  in  the  urinary  tract.  It  is  either 
coagulated  in  the  urine  when  passed  or  precipitated  by 
standing,  and  forms  a  flaky  sediment  or  a  thick  coagulum . 

Fibrin  shows  the  characteristics  of  coagulated  albumin,  insolubility 
in  water  and  saline  solutions  as  well  as  in  diluted  acids  and  alkalies. 
It  is  converted  in  the  cold  by  alkalies  into  a  thick  coagulum  which 
dissolves  after  prolonged  heating.  Solutions  of  fibrin  react  to  the 
tests  for  albumin. 

13.  Nucleo-Albumin  (Mucin). — This  body,  formerly 
called  mucin,  now  nucleo-albumin,  is  probably  in  small 


THE    URINE.  17 

quantities  a  normal  product  of  the  mucous  membrane 
of  the  urinary  tract,  but  when  found  in  increased  quan- 
tity it  indicates  a  catarrhal  condition.  It  is  recognized 
on  account  of  its  precipitation  by  acetic  acid  and  its 
weak  solubility  in  an  excess  of  the  acid,  especially  if 
few  salts  are  present. 

Dilute  the  urine  with  1-2  volumes  of  water  and  add  acetic  acid. 
If  nucleo-albumin  is  present,  a  marked  cloudiness  results.  This 
disappears  on  the  addition  of  caustic  soda  and  reappears  when  more 
acetic  acid  is  added. 

14.  Albumose. — Albumose,  an  intermediate  product 
between  albumin  and  peptone,  has  repeatedly  been 
detected  in  the  urine  in  different  diseases  as  osteoma- 
lacia, intestinal  ulcer,  and  especially,  in  often  large 
quantity,  in  multiple  myeloma.  It  has  also  been  found 
in  urine  containing  the  seminal  fluid  as  albumose  is  a 
constituent  of  that  secretion. 

Urine  containing  albumose  shows  the  following  reactions  : 

(i)  Urine   rendered  weakly   acid,    if   necessary,   with  acetic  acid 

becomes  cloudy  when  heated  to  60°  C.  (140°  F.),  clear  when  boiling, 

and  again  cloudy  when  cold. 

(2)  A  few  drops  of  nitric  acid  are  added  to  urine  which  has  been 
boiled  (as  in  Test  i  for  albumin).  A  precipitate  appears  when  the 
solution  is  cold.     It  is  dissolved  by  heat  and  reappears  when  cold. 

(3)  A  small  quantity  of  acetic  acid  and  a  few  drops  of  a  solution  of 
ferrocyanide  of  potassium  produce  a  cloudiness  distinguished  from 
albumin  by  its  solubility  in  heated  solution  and  its  reappearance 
when  the  solution  is  cold. 

(4)  Sodium  chloride  in  crystals  added  to  saturation  produces  a 
precipitate  which  dissolves  on  the  addition  of  acetic  acid  and  the 
application  of  heat.  If  albumin  is  present,  the  precipitate  remains 
or  then  forms.  It  should  be  filtered  while  hot  and  allowed  to  cool. 
If  the  precipitate  re-forms  albumose  is  present. 


1 8  A    CLINICAL  MANUAL. 

15.  Peptone. — Small  quantities  of  peptone  have 
been  found,  though  not  invariably,  in  the  urine  of  cases 
characterized  by  a  rapid  retrograde  metamorphosis  of 
normal  and  pathological  tissues,  e.  g.,  in  the  involution 
of  the  puerperal  uterus,  in  acute  atrophy  of  the  liver, 
and  phosphorus  poisoning,  after  hemorrhages,  in  carci- 
noma, phthisis,  croupous  pneumonia,  extensive  exudates, 
and  in  nearly  all  suppurative  conditions. 

It  is  very  soluble  in  water,  does  not  coagulate  when 
boiled,  and  shows  no  reaction  with  the  majority  of  the 
common  reagents  employed  for  the  detection  of  albumin 
— nitric  acid,  acetic  acid  -j-  sodium  chloride,  acetic  acid 
-j-  ferrocyanide  of  potassium.  It  is  precipitated  by 
metaphosphoric  acid,  phospho-tungstic  acid,  potassio- 
mercuric  iodide  -[-  acetic  acid.  These  reactions  cannot, 
however,  be  employed  for  the  special  determination  of 
peptone  in  urine,  as  they  are  neither  characteristic  nor 
sufficiently  sensitive.  It  must  first  be  isolated  and  then 
tested.  The  method  of  Hofmeister  is  the  one  commonly 
employed. 

Hofmeisier's  Test. — A  large  quantity  of  urine  (20  ounces),  which 
has  been  found  free  from  albumin,  is  treated  with  neutral  acetate 
of  lead  and  then  filtered.  The  filtrate  is  acidulated  with  hydrochloric 
acid  and  phospho-tungstic  acid  ^  is  added  until  a  precipitate  ceases 
to  form,  and  it  is  then  immediately  filtered.  The  precipitate,  which 
contains  peptone  combined  with  phospho-tungstic  acid  and  also  other 
substances,  is  washed,  in  order  to  remove  the  salts  present  on  the 
filter,  with  a  solution  of  5  parts  of  concentrated  sulphuric  acid  in  100 
parts  of  water,  until  the  fluid  passing  through  is  colorless.  The 
precipitate  is  removed  from  the  filter  with  as  little  water  as  possible 

^  Phospho-tungstic  acid  is  made  by  dissolving  tungstate  of  soda  in 
boiling  water  and  adding  phosphoric  acid  until  the  solution  is  acid. 
"When  cold  it  is  rendered  strongly  acid  with  hydrochloric  acid,  and 
after  standing  for  twenty-four  hours  is  filtered. 


THE    URINE.  19 

into  a  porcelain  dish  and  barium  carbonate  is  added  until  the  mix- 
ture becomes  alkaline.  It  is  then  placed  on  a  water-bath  at  the 
boiling  point  and  heated  for  10-15  minutes  and  the  biuret  test 
applied.  This  test  consists  of  the  addition  of  caustic  potash  and  a 
drop  or  two  of  a  diluted  (10  ^)  solution  of  sulphate  of  copper.  A 
bluish-red  to  violet  color  appears  if  peptone  is  present. 

If  the  urine  contains  albumin,  it  should  be  removed  by  combining 
it  with  iron  oxide.  The  urine  is  treated  with  a  solution  of  acetate 
of  soda  and  then  with  one  of  chloride  of  iron  and  exactly  neutralized 
with  caustic  potash,  then  boiled,  filtered,  and  when  cold  examined  for 
albumin  by  Tests  i  and  3  (heat  and  acetic  acid  -j-  ferrocyanide  of 
potassium  tests).  If  both  are  negative  and  no  blue  color  (due  to  iron) 
results  with  Test  3,  it  should  be  examined  for  peptone,  as  described 
above.  If  the  tests  show  that  a  trace  of  albumin  is  present,  the 
removal  of  the  albumin  must  be  repeated  until  no  albumin  or  iron  can 
be  detected. 


16.  Blood  in  the  Urine. — The  color  of  the  urine  may 
be  yellowish-red,  red,  brown,  or  brownish-black,  de- 
pending upon  the  quantity  and  form  of  haemoglobin. 
The  haemoglobin  may  have  the  form  of  oxy-haemoglobin 
(red  urine)  ;  met-haemoglobin  (brown  urine),  and  may 
appear 

(a)  dissolved  in  the  urine  (haemoglobinuria), 

(b)  enclosed  in  red  blood  corpuscles  (haematuria). 
This  must  be    determined    by    the  microscopical   ex- 
amination. 

The  pigment  of  the  blood  is  oxy-haemoglobin  in  all 
excessive  hemorrhages  from  the  bladder ;  met-hasmo- 
globin  in  all  forms  of  haemoglobinuria,  in  many  hemor- 
rhages from  the  kidneys,  and  in  slight  hemorrhages  from 
the  bladder.  The  presence  of  haemoglobin  in  any  quan- 
tity is  recognized  by  the  red  color  of  the  urine.  The 
met-haemoglobin  is  after  a  time  converted  into  oxy- 
haemoglobin  or  reduced  haemoglobin.     The  presence  of 


20 


A    CLINICAL  MANUAL, 


haemoglobin    may  be  determined  by   the    spectroscopic 
examination  or  by  various  tests. 

Spectroscopic  Examination. 

OxY-H^MOGLOBiN. — Its  aqueous  solutions  are  charac- 
terized by  a  bright-red  color  and  two  absorption  lines  in 
the  spectrum.  These  are  easily  recognized  in  a  layer 
of  diluted  urine  (even  to  o.oi  per  cent.)  \-\  inch  thick 
with  a  good  pocket  spectroscope  and  bright  daylight 
(Fig.  3,  A  and  b). 


Spectrum  of 
Oxy-haemoglobin. 


M  et-hae  moglobin. 
Reduced  hsemoglobin. 


FIG.   3. 

Met-h^moglobin. — This  has  the  same  quantity  of 
oxygen  as  oxy-hsemoglobin,  but  in  stronger  union.  It  is 
formed  from  oxy-hsemoglobin  by  the  addition  of  acids 
and  acid  salts  (hence  its  presence  in  urine).  It  is  charac- 
terized in  acid  and  neutral  solutions  by  its  brown 
color  and  by  two  more  lines  in  the  spectrum  ;  all  four 
lines  (Fig.  3,  aa'  bb')  are  visible  only  when  a  large  per- 
centage of  met-hsemoglobin  is  present.  If  the  solution 
is  greatly  diluted  the  line  a'  alone  appears. 

Reduced  hssmoglobin. — This  is  formed  from  the 
two  just  described  by  de-oxidation.  It  is  characterized 
in  moderately  weak  solutions  by  a  greenish,  brownish, 


THE    URINE.  21 

red  color,  and  by  a  broad,  ill-defined  absorption  line 
(Fig.  3).  On  shaking  with  air  it  is  transformed  into 
oxy-haemoglobin. 

Haemoglobin,  when  boiled  or  treated  with  acids  or 
alkalies,  is  split  up  into  hsematin  and  albumin.  Haematin 
is  amorphous,  of  a  brownish-black  color,  insoluble  in 
water  and  acids,  very  soluble  in  alkalies,  somewhat 
soluble  in  warm  glacial  acetic  acid,  out  of  which  it 
separates  in  characteristic  rhomboidal  crystals  (haemin 
crystals,  Fig.  4)  when  a  crystal  of  sodium  chloride  is 
added. 

1.  Heat  Test. — Boil  the  urine  ;  a  brown  coagulura 
forms  ;  not  sensitive.  If  the  urine  is  alkaline  there  is 
often  merely  a  brown  coloration  and  the  coagulum  forms 
only  after  the  addition  of  acetic  acid. 

2.  Heller  s  Test. — The  urine  is  made  alkaline  with 
caustic  soda  and  then  boiled.  A  flaky  blood-red  pre- 
cipitate of  the  earthy  phosphates  results. 

If  the  quantity  of  haemoglobin  is  small  the  precipitate 
becomes  visible  only  when  it  sinks  to  the  bottom  of  the 
tube. 

This  reaction  is  based  upon  the  formation  of  haematin  which  is 
taken  up  by  the  earthy  phosphates  precipitated  by  the  alkali.  In 
urine  free  from  the  pigment  of  the  blood,  the  precipitate  of  the  phos- 
phates is  white.  Dark-brown  flakes  form  when  too  little  or  too  much 
caustic  soda  has  been  added  or  when  the  solution  is  over-heated. 
These  are  not  so  readily  recognized  as  the  blood-red,  but  are  equally 
characteristic. 

Frequently  in  alkaline  urine  no  precipitate  forms,  especially  if  all 
the  calcium  phosphate  has  settled  as  sediment.  In  such  cases  the  test 
should  be  repeated  with  the  addition  of  a  calcic  salt. 

After  the  use  of  chrysarobin,  rhubarb,  and  senna,  a  yellow  pigment 
(chrysophanic  acid)  appears  in  the  urine.  This  becomes  red  in  alkaline 
urine,  and  when  heated  is  precipitated  in  red  flakes  with  the  phos- 


22  A    CLINICAL   MANUAL. 

phates.  The  differentiation  is  easy.  The  precipitate  of  the  phos- 
phates is  soluble  in  acetic  acid,  while  the  hasmatin  remains  in 
dark-brown  flakes.  Such  urine  can  also  be  examined  by  Tests  i,  3, 
and  4.  If  a  large  quantity  of  chrysophanic  acid  is  present,  it  may  be 
recognized  by  the  red  color  of  the  urine,  especially  the  foam,  upon 
the  addition  of  caustic  soda. 

The  urine  gives  the  same  reaction  after  the  administration  of  san- 
tonin.    Differentiate  by  No.  39. 

3.  Almcfis  Test. — An  emulsion  of  freshly  prepared 
tincture  of  guaiac  and  oxidized  (/.  <?.,  old  and  exposed  to 
the  air)  oil  of  turpentine,  equal  parts,  is  carefully  poured 
upon  the  urine.  At  the  junction  of  the  fluids  a  white  ring, 
due  to  the  precipitation  of  resin,  forms.  If  haemoglobin 
is  present,  the  ring  is  immediately  colored  a  beautiful 
blue. 

This  test  is  even  more  sensitive  than  the  spectral  test  for  haemo- 
globin. Its  action  depends  on  the  transference  of  the  ozone  of  the 
oil  of  turpentine  to  the  guaiac  resin  by  the  haemoglobin,  thus  oxidiz- 
ing (coloring  blue)  the  guaiac. 

It  should  be  kept  in  mind  that  the  guaiac  resin  is  colored  blue  by 
pus  even  without  the  addition  of  turpentine.  When  the  urine  is 
alkaline  the  test  is  less  sensitive.  It  is  therefore  well  to  acidulate 
with  acetic  acid  before  testing.  A  tincture  of  one  part  of  guaiac 
resin  and  eighteen  parts  of  alcohol  makes  a  very  sensitive  reagent. 
This  should  be  made  up  as  required,  or  at  least  kept  in  a  dark  glass 
bottle.  The  oil  of  turpentine  should  be  exposed  in  a  half-filled 
bottle  to  the  light.  The  reagents  should  occasionally  be  tested  with 
urine  to  which  blood  has  been  added. 

4.  Test  for  Hceinin  Crystals. — The  precipitate  obtained 
by  test  I  or  2  is  collected  on  a  small  filter,  washed 
thoroughly,  and  dried  by  gentle  heat.  Place  a  small 
quantity  upon  a  slide,  add  to  it  a  crystal  of  sodium 
chloride,  and  lay  upon  it  a  cover  glass.  Allow  a  few 
drops  of  glacial  acetic  acid  to  flow  beneath  the  cover 


THE    URINE.  23 

glass,  and  heat  the  preparation  over  a  small  flame  for  a 
minute  to  a  point  below  boiling.  Replace  the  glacial 
acetic  acid,  as  it  evaporates,  with  fresh  acid,  drop  by 
drop.     If  hsematin  is  present, 

the    fluid  gradually  becomes  ^   «  ^  J^     Tl     y  ^ 
brownish-red.     When  this  oc-       ^    J^  IJ  ^^^\n 
curs,  remove  the  preparation    ^   ^ ^^ (^K^y>  ^'^%^ 
some  distance  from  the  flame     \\    "^U  ^^^  ^^n  \^ys 
until  it  cools  and  the  glacial 

acetic  acid  evaporates.  Look  ^^^-  4.-h^min  crystals. 
for  the  crystals  of  haemin  (Fig.  4)  when  the  objective 
of  the  microscope  has  been  focused  on  the  brown  spots. 
Beautiful  preparations  of  haemin  crystals  may  be  obtained 
by  gently  evaporating  a  drop  of  blood  on  a  slide  and 
treating  it  in  the  manner  just  described. 

II.— COLORING   MATTERS. 

17.  Bile-Pigments. — The  presence  of  biliary  acids  in 
the  urine  can  be  detected  only  by  methods  so  tedious 
as  to  be  useless  for  clinical  purposes.  When  Petten- 
kofer's  test  with  cane  sugar  and  sulphuric  acid  is 
employed,  the  presence  of  bodies  which  yield  a  similar 
violet-red  color,  renders  the  result  so  uncertain  that  0.5 
per  cent,  of  biliary  acid  must  be  present,  which  rarely 
occurs  in  icterus,  to  secure  an  undoubted  reaction. 

The  recognition,  however,  of  the  presence  of  the  bile- 
pigments  is  a  comparatively  simple  matter,  and  therefore 
of  much  more  clinical  importance.  The  bile-pigments 
are  bilirubin  (yellow  or  brown)  and  biliverdin  (green). 
They  are  insoluble  in  water  and  acids,  soluble  in  alkalies 
from  which  they  are  precipitated  in  reddish-brown  or 
green    flakes   by  salts   of  lime.     They    form  with    lime 


24  A    CLINICAL  MANUAL. 

compounds  insoluble  in  water  (such  is  the  combination 
in  gall-stones). 

Bilirubin  is  insoluble  in  alcohol,  soluble  with  a  yellow 
coloration  in  chloroform,  and  crystallizes  out  of  it  in 
brownish-red  prisms  and  small  plates. 

BiLiVERDiN  is  on  the  contrary  insoluble  in  chloroform, 
but  soluble  in  alcohol,  out  of  which  it  crystallizes  in 
imperfectly  defined  shapes. 

Icteric  urine  is  yellowish-green  to  dark-brown,  and 
when  shaken  shows  a  yellow  foam.  The  sediment 
present  (oxalate  of  calcium,  casts,  epithelium)  often  has 
a  beautiful  yellow  color. 

I.  Gmelins  Test. — Filter  some  urine  and  touch  the 
inner  side  of  the  still  wet  filtering  paper  with  a  drop 
of  yellow  concentrated  nitric  acid.  If  bile-pigment  is 
present,  concentric  color-rings  appear  on  the  spot 
touched,  on  the  outside  a  green,  then  blue,  violet,  red, 
and  yellow  rings. 

This  test  proposed  by  Rosenbach  is  a  very  sensitive  modifica- 
tion of  the  original  Gmelin's  test,  in  which  the  urine  is  carefully 
poured  on  concentrated  nitric  acid,  and  the  same  play  of  colors 
appears  in  the  form  of  rings  one  above  another.  The  sensitiveness  of 
the  test  increases  with  the  quantity  of  urine  filtered.  Not  less  than 
50-100  c.c.  (2-3  ounces)  should  be  filtered. 

This  reaction  is  the  result  of  the  oxidation  of  bilirubin  into  other 
pigments  of  which  biliverdin  (green  color)  results  first.  The  reaction 
is  possible  only  when  the  nitric  acid  has  a  yellow  color,  /.  e.,  holds 
some  nitrous  acid.  This  results  from  the  long  exposure  of  nitric 
acid  to  light,  or  more  rapidly  by  heating  it  with  a  small  piece  of 
wood  or  sugar. 

The  filtering  paper  used  must  be  free  from  impurities.  If  it  con- 
tains coloring  matter,  this  may  show  the  reaction  with  nitric  acid. 
It  should  be  tested  before  being  used  with  a  drop  of  nitric  acid. 

All  specimens  of  urine,  though  highly  colored,  and  certainly 
icteric,  do  not  react  positively  to  Gmelin's  test.    If  little  bile  pigment 


THE    URINE.  25 

is  present,  the  play  of  colors  may  be  entirely  hidden  by  other  pig- 
ments, urobilin,  and  the  like.  In  such  cases  either  the  urobilin 
should  first  be  separated  from  the  urine  by  acidulating  and  shaking  with 
chloroform,  in  which  it  is  dissolved,  with  a  yellow  coloration,  or  the 
following  special  tests  may  be  employed. 

2.  Hupperf s  Test. — Add  to  urine  lime-water  or  a 
solution  of  barium  chloride  -j-  caustic  soda.  The  result- 
ing precipitate  is  separated  by  filtration  and  boiled  with 
alcohol,  to  which  a  few  drops  of  diluted  sulphuric  acid 
have  been  added  :  a  beautiful  green  solution  results  if 
bile-pigment  is  present  ;  a  deep  rose  color  if  urobilin  is 
contained  in  the  urine  ;  a  bluish-gray  precipitate  at  the 
outset  and  later  not  a  green,  but,  if  any,  a  yellow  or 
reddish  color  results  if  indican  is  present. 

3.  Stokois's  Test. — 20-30  c.c.  (one  ounce)  of  urine  are 
precipitated  by  5-10  c.  c.  (i-2j-  drachms)  of  a  20  per 
cent,  solution  of  zinc  acetate.  The  precipitate  is  collected 
on  filtering  paper,  washed,  and  dissolved  in  ammonia 
water.  The  solution  assumes  immediately  or  after  expo- 
sure to  the  air  a  brownish-green  color  with  fluorescence, 
and  presents  in  the  spectrum  the  characteristic  absorp- 
tion bands  of  cholecyanin  (bilicyanin),  viz.,  a  sharp  line 
at  c,  a  faint  one  at  d,  and  a  very  faint  one  between  d 
and  E. 

4.  Iodine  Test. — Pour  carefully  with  a  pipette  upon 
urine  in  a  test-tube,  a  drachm  of  a  diluted  (10  per  cent.) 
alcoholic  solution  of  the  tincture  of  iodine.  If  bile- 
pigment  is  present,  a  grass-green  ring  forms  at  the 
plane  of  contact  of  the  two  fluids.  If  no  bile-pigment 
is  present,  only  a  light-yellow  or  colorless  ring  appears. 

18.  Urobilin. — Urobilin  is  the  result  of  a  metamor- 
phosis of  the  pigment  of  the  blood,  and  also  of  a  reduc- 
tion of  bilirubin,  and  therefore  also  called  hydrobilirubin. 


26  A    CLINICAL  MANUAL. 

It  is  an  amorphous,  reddish-brown  substance,  soluble  with  diffi- 
culty in  water,  very  soluble  in  alcohol,  chloroform,  and  alkalies  ;  it 
forms  insoluble  salts  with  the  earthy  and  heavy  metals,  and  does  not 
react  to  Gmelin's  test  for  bile-pigment.  Small  quantities  are  present 
even  in  normal  urine  in  the  form  of  a  chromogen,  which  is  easily 
converted  into  urobilin,  especially  in  the  presence  of  acids.  It  is 
found  in  large  quantity  in  cases  characterized  by  disintegration  of 
red  corpuscles,  as  after  fever  and  extravasation  of  blood  (cerebral 
hemorrhage,  hemorrhagic  infarct,  retro-uterine  hematocele,  extra- 
uterine pregnancy,  scorbutus,  etc.).  It  may  also  occur  in  hepatic 
disease,  most  commonly  in  hepatic  cirrhosis  and  congestion.  The 
urine  in  these  cases  is  always  of  an  intensely  brownish-red  color,  and 
often  has  a  yellow  foam  like  icteric  urine. 

1.  Spectral  Test. — Urine  rich  in  urobilin  shows  an 
absorption  line  between  green  and  blue  answering  about 
to  the  position  of  the  fourth  met-haemoglobin  line  (Fig.  3, 
b').  The  line  is  more  distinct  in  acid  than  in  alkaline 
urine,  in  which  it  is  deflected  to  the  left. 

2.  Fluorescence  Test. — Five  drops  of  a  10  per  cent, 
solution  of  chloride  of  zinc  are  added  to  the  urine, 
then  ammonia  until  the  precipitate  formed  is  dissolved 
by  shaking.  If  urobilin  is  present  in  not  too  small  a 
quantity,  a  green  fluorescence  becomes  visible  when  it  is 
held  against  a  dark  background  after  the  precipitated 
phosphates  have  settled. 

Urobilin  is  in  this  reaction  precipitated  as  a  zinc  salt  and  then 
redissolved  by  the  ammonia.  All  solutions  of  urobilin  are  fluores- 
cent. Urine  very  rich  in  urobilin  often  exhibits  this  property  before 
it  is  tested.  The  solutions  of  zinc  salts  possess  this  characteristic  in  a 
marked  degree. 

Very  small  quantities  of  urobilin  cannot  be  recognized  in  urine. 
The  urobilin  must  first  be  isolated  by  shaking  the  acidulated  urine 
with  chloroform,  and  then  abstracted  by  treating  it  with  a  diluted 
solution  of  caustic  soda. 

19.  Indican  {^Indoxyl-sulphuric  acid  C^Hf^NOSOjOH^. 
— A  product  of  albuminoid  retrograde  metamorphosis  in 


THE    URINE.  27 

the  intestinal  canal,  and  therefore,  in  small  quantities,  a 
normal  element.  It  appears  in  large  quantities  in  a 
meat  diet,  simple  constipation,  digestive  disorders,  car- 
cinoma of  the  stomach,  liver,  or  ileum,  typhoid  fever, 
tuberculosis  of  the  intestine,  peritonitis,  and  in  internal 
suppuration. 

yaffes  Test. — Fill  a  test-tube  one  half  with  urine, 
add  an  almost  equal  quantity  of  concentrated  hydro- 
chloric acid,  then  2-3  c.c.  (|  drachm)  of  chloroform  and 
one  drop  of  a  moderately  saturated  solution  of  chloride 
of  lime.  Mix  by  inverting  the  test-tube,  closed  with  the 
thumb,  a  number  of  times.  If  indican  is  present,  a  blue 
coloration  appears  in  the  lower  part  of  the  fluid. 

This  reaction  is  due  to  the  splitting  of  indican  into  indoxyl  and 
sulphuric  acid  by  the  hydrochloric  acid  and  the  oxidation  of  the 
indoxyl  into  indigo  blue  by  the  lime.  The  indigo  blue,  insoluble  in 
water,  is  precipitated  as  a  finely  divided  blue  sediment  and  is  taken  up 
by  the  chloroform.  If  more  lime  be  added  drop  by  drop,  the  blue 
color  disappears  when  there  is  but  little  indican  present,  as  the 
indican  is  further  oxidized  to  yellow  isatin.  If  the  urine  is  very  rich 
in  indican,  the  blue  color  is  at  first  intensified,  and  then,  after  the 
addition  of  more  of  the  solution  of  lime,  changes  to  a  yellow.  This 
characteristic  allows  an  approximate  quantitative  estimation  of  indi- 
can to  be  easily  made.  The  shaking  with  chloroform  should  not 
be  vigorous,  as  an  emulsion  will  be  formed  with  the  urine. 

Urine  containing  albumin  should  have  previously  been  freed  from 
it.  A  1-2  per  cent,  solution  of  permanganate  of  potassium  may  be 
employed  instead  of  the  lime,  but  it  must  be  mixed  longer  with  the 
chloroform  and  frequently  added  until  the  maximum  of  color  results. 

III.— GRAPE  SUGAR  (DEXTROSE). 

20.  Glycosuria. — Grape  sugar  has  often  (18  in  100 
cases)  been  found  in  small  quantity  in  normal  urine, 
and    especially   after   the   consumption    of   an  unusual 


28  A    CLINICAL  MANUAL. 

quantity  of  sugar  (^physiological  glycosuria)  ;  it  may  be 
the  result  of  an  excretion  of  milk  sugar  in  the  urine  of 
nursing  mothers  {lactosuria)^  and  may  also  occur  as  an 
occasional  and  temporary  accompaniment  of  many  dis- 
eases, as  infectious  diseases,  diseases  of  the  heart  and 
lungs,  cirrhosis  of  the  liver,  and  nervous  disorders 
{transitory  glycosuria). 

An  increased  secretion  of  sugar,  which  cannot  be  at- 
tributed to  any  of  the  above  causes,  which  is  a  continu- 
ous condition  {^persistent  glycosuria)  with  a  mixed  diet, 
diminishes  or  disappears  under  a  meat  diet,  increases 
under  a  diet  rich  in  carbo-hydrates,  is  the  most  certain 
and  usually  the  earliest  symptom  of  diabetes  mellitus. 

The  quantity  of  sugar  found  in  the  urine  in  diabetes 
mellitus  is  usually  not  more  than  4  per  cent.  ;  in  very 
severe  cases  5-6  per  cent.  ;  and  very  rarely  a  larger 
quantity  up  to  10  per  cent.  (500  grams  daily). 

Whenever  urine  has  a  specific  gravity  of  1020  or 
more,  is  very  pale,  clear,  and  without  sediment,  and  in- 
creased in  amount,  it  should  be  examined  for  sugar. 

I.  Test  of  Moore  and  Heller. — Add  to  the  urine  in  a 
test-tube  J-^  its  volume  of  caustic  soda  and  boil  2-3 
minutes.  If  sugar  is  present,  the  urine  becomes  a  dark- 
yellow  to  a  dark-brown,  the  color  varying  with  the 
quantity  of   sugar. 

This  reaction  is  due  to  the  oxidation  of  the  grape  sugar,  and  is 
very  sensitive  in  a  solution  of  pure  sugar.  In  urine,  however,  it  is 
characteristic  of  sugar  only  when  a  large  quantity  of  sugar  is  present 
— i.  e. ,  when  the  pronounced  brown  color  appears,  as  the  dark-yellow 
color  can  be  produced  by  heating  urine,  free  from  sugar,  with  caustic 
soda. 

The  flaky  precipitate  usually  observed  in  this  test  consists  of  the 
earihy  phosphates.  These  are  precipitated  in  the  cold  by  the  caustic 
soda  and  form,  when  heated,  large  flakes.    This  is  a  normal  condition. 


THE    URINE.  29 

2.  Trommers  Test. — Add  to  the  urine  \  its  volume 
of  caustic  soda,  and  with  strong  shaking  a  solution  of 
cupric  sulphate  drop  by  drop  until  a  small  quantity  of 
copper  remains  undissolved.  If  the  urine  dissolves 
much  copper  and  at  the  same  time  assumes  a  beautiful 
blue  color,  the  presence  of  sugar  is  probable. 

Then  heat  to  just  below  the  boiling  point  (the  upper 
part  of  the  solution  only  should  be  heated)  ;  if  the  part 
heated  shows  yellowish-red  lines  or  heavy  flakes  of  pre- 
cipitated cupric  suboxide  separated  sharply  from  the 
rest  of  the  fluid  which  continues  blue,  and  if  this 
precipitate  gradually  forms  through  the  entire  solution, 
the  presence  of  sugar  is  proved. 

Trommer's  test  acts  in  this  typical  way  only  in  pronounced  dia- 
betic urine.  In  many  cases  the  urine  dissolves  a  large  quantity 
of  cupric  oxide,  the  blue  color  is  changed  on  heating  to  a  yellow  or 
brown  ;  a  precipitation  of  cupric  suboxide  does  not,  however,  result, 
or  it  occurs  only  after  a  long  time  (a  brown  precipitate  of  the  earthy 
phosphates  with  some  cupric  oxide  may  lead  to  error).  It  is  often 
possible  in  such  cases  to  obtain,  by  exact  saturation  with  cupric 
sulphate,  a  precipitate  while  the  solution  is  being  heated. 

It  is  often  very  diflicult  to  decide  when  the  sulphate  of 
copper,  which  is  being  added,  ceases  to  be  dissolved,  as 
a  marked  cloudiness  appears  in  many  specimens  of  urine 
immediately  after  the  addition  of  the  caustic  soda.  In 
such  cases  it  is  advisable  to  carry  out  Trommer's  test  in 
the  following  manner  : 

Add  to  a  quantity  of  urine,  sufficient  for  4  tests,  caustic 
soda  and  cupric  sulphate  as  described,  until  the  solution 
seems  saturated  with  sulphate  of  copper.  Pour  \  of 
this  mixture  into  a  test-tube  and  heat  it.  If  no  precipitate 
of  suboxide  forms  while  a  yellow  coloration  appears,  add 
to  the  remaining  parts  some  additional  cupric  sulphate 


30  A    CLimCAL  MANUAL, 

and  test  \  of  this  mixture  ;  continue  adding  cupric  sul- 
phate to  the  remainder  and  testing  in  the  same  manner 
until  a  precipitate  of  suboxide  forms  or  until  the  solution 
has,  after  heating,  a  permanent  green  color,  indicating  a 
surplus  of  copper  which  cannot  be  reduced.  In  the  first 
case  the  presence  of  sugar  is  proved,  in  the  second 
Trommer's  test  leaves  the  question  in  doubt  as  this 
reduction  (change  of  color)  may  be  due  to  sugar  or  may- 
be caused  by  other  reducing  substances.  Positive  dif- 
ferentiation is  possible  only  by  tests  3,  4,  or  5. 


An  answer  to  the  questions — ^why  the  precipitation  of  cupric  sub- 
oxide does  not  always  follow,  why  it  must  occur  for  proof  of  sugar, 
and  why  the  color  reaction  alone  is  not  sufficient  ? — is  given  by  a 
knowledge  of  the  chemical  principles  underlying  these  reactions  and 
of  their  relation  to  normal  urine.  It  will  thus  become  evident  how 
absolutely  necessary  it  is  to  adhere  strictly  to  the  directions  in  making 
this  test. 

Reaction  between  I.  Add  to  water  caustic  soda  and  a  solution  of 
caustic  soda  and  cupric  sulphate,  a  heavy  blue  precipitate  of  cupric 
cupric  sulphate.  hydroxide  forms  CuS04  +  2NaOH  =  Na^  S04  + 
Cu  (OHjg.  This  is  insoluble  in  caustic  soda  and  when  heated  is 
converted  into  a  brownish  black  cupric  oxide  CuO,  more  accurately 
Cu(OH)3  +  2CuO. 

Substances  which  2.  If  the  water  contains  certain  substances 
dissolve  cupric  as  glycerine,  tartrates,  ammonia,  albumin,  or  grape 
°^^*^^-  sugar,  the  precipitate  of  cupric  hydroxide  is  dis- 

solved, by  shaking,  into  a  blue  liquid.  This  property  of  dissolving 
cupric  oxide  is  therefore  not  a  characteristic  of  grape  sugar  alone. 

3.     The  blue  color  in  the  above  solution  when  boiled  is  affected 

^ differently  ;  if  glycerine,  tartaric  acid,  ammonia,  or 

Different  results  J   ^         b  J 

when  heated         albumin  is  present  no  change  ensues,  but  if  sugar  is 

present  a  yellow  or  red  precipitate  of  cupric  sub- 
oxide immediately  forms  and  the  solution  assumes  this  color. 

This  phenomenon  is  due  to  the  oxidation  of  the  sugar.  The 
sugar  in  heated  alkaline  solution  attracts  from  the  cupric  oxide  a  part 


THE    URINE.  31 

of  its  oxygen  and  converts  it  into  red  cupric  suboxide  CugO  or  yellow 

cupric  suboxide  hydrate  Cug(0H)2. 

This  property  of  reducing  cupric  oxide  is,  however, 

,.      ^                                ,  Reducing 

not  peculiar  to  grape  sugar  alone  as  many  organic  ,    . 

^                      *»     ^          =>                                    /fa  substances. 

bodies  share  with  it  this  characteristic.     They  are 
called  by  the  generic  term  reducing  substances. 

Some  of  the  reducing  substances  are  found  in  the  urine  and  their 
presence  in  normal  urine  is  easily  detected  by  Trommer's  test.  This 
leads  to  the  recognition  of  an  important  property  of  normal  urine. 

4,  If  caustic  soda  is  added  to  normal  urine,  a  precipitate  of  earthy 

phosphates   forms.      This   is  scarcely  visible  at  first,   but  gradually 

falls  to  the  bottom  in  colorless  flakes.    If  a  solution  of  cupric  sulphate 

is  now  added  drop  by  drop,  each  drop  will  produce 

a  heavy  blue  precipitate  of  cupric  hydroxide  which   P°wer  of  normal 

urine  to  dissolve 
IS    redissolved  by  shaking.      If  cupric  sulphate  is  ^^^  reduce 

added  until  a  small  quantity  of  the  copper  (3  to  5  cupric  oxide, 
drops)  remains  insoluble,  and  if  the  resulting  bluish- 
green  solution  is  boiled,  the  color  is  changed  into  yellow  when 
examined  by  reflected  light,  and  to  a  reddish-yellow  by  refracted 
light.  The  cupric  oxide  has  been  reduced  but  the  copper  is  not 
precipitated  as  the  fluid  remains  perfectly  clear.  The  precipitate  of 
the  phosphates  is  clearly  visible,  and  after  it  sinks  to  the  bottom  it  is 
of  a  reddish-brown  color,  due  to  traces  of  cupric  suboxide  which 
accompany  it. 

This  reaction  shows  : 

(a)  That  the  normal  urine  contains  substances  which  dissolve 
cupric  oxide  (uric  acid,  kreatinin,  salts  of  ammonia). 

(b)  That  it  contains  substances  which  reduce  cupric  oxide  (uric 
acid,  pyrocatechin,  etc.). 

(c)  That  it  contains  substances  which  dissolve  cupric  sub-oxide 
(uric  acid,  kreatinin,  salts  of  ammonia,  etc.).  The  power  of  the 
normal  urine  to  diss-olve  and  reduce  cupric  oxide  is  not  great  and 
is  overcome  by  3  to  5  drops  of  cupric  sulphate.  Much  more  im- 
portant is  the  power  to  dissolve  cupric  suboxide  as  the  following 
experiment  shows. 

5.  Add  to  normal  urine  about  0.5  per  cent,  of  grape  sugar  and 
proceed  ars  before.  The  same  phenomena  ensue  but  more  markedly  ; 
a  fairly  strong  solution  of  CuO,  a  pronounced  yellow  coloration  on 
heating,  but  no  precipitation  of  cupric  suboxide  during  or  immediately 


32  A    CLINICAL   MANUAL, 

after  heating.  The  cause  of  this  phenomenon  is  the  great  power  of 
the  normal  urine  to  dissolve  cupric  suboxide  (CugO)  on  account  of 
which  not  only  the  suboxide  which  the  reducing  bodies  have  formed, 
but  also  that  due  to  the  oxidation  of  the  sugar,  will  be  held  in  solu- 
tion. The  precipitate  will  first  appear  when  the  quantity  of  sugar  is 
very  large  and  much  cupric  suboxide  is  formed  of  which  all  is  not 
dissolved. 

6.  The  normal  urine,  to  which  0.5  per  cent,  sugar  has  been 
added,  acts  in  the  same  manner  as  the  previously  described  patho- 
logical urine  with  incomplete  action  of  Trommer's  test  (failure  of 

the  precipitation  of  cupric  suboxide).     Such  urine 
The  precipitation     may  contain  sugar  but  there  is  no  proof   of   it, 
o  cupric  su  oxide    ^^  ^^  reduction  may  be  due  to   other  reducing 
IS  alone  proof  of 
gy  substances,  which,  as  has  been  shown,  are  present 

in  greater  or  less  quantity  in  urine. 
When  the  precipitation  of  cupric  suboxide  is  added  to  its  reduction, 
the  presence  of  sugar  is  proved,  as  it  is  known  from  experience  that 
no  other  reducing  body,  which  can  produce  a  precipitate  of  cupric 
suboxide,  is  present  in  the  urine. 

7.  The  conclusion  that  sugar  is  present  from  the  precipitation  of 

cupric  suboxide  is  permitted  only  when  the  tern- 
Necessity  of  keep-    perature  during  the  test  remains  below  the  boiling 

ing  e  emper-  point.  Therefore  urine  should  be  heated  to  just 
ature  below  the         ^  .  ^ 

boiling  point.  below  the  boiling  point.     Boiling,  especially  when 

prolonged,   may   produce  a  precipitate  of  cupric 

suboxide  in  many  specimens  of  normal  urine,  usually,  however,  not. 

during  the  boiling  but  only  after  it  has  become  cold. 

8.  As  the  urine  contains  bodies  capable  of  dissolving  cupric  sub- 
oxide, it  is  necessary,  especially  when  the  quantity  of  sugar  is  small 
and  the  urine  concentrated,   to  obtain  the  formation  of  the  largest 

quantity  of   cupric   suboxide  possible,  as  the  prob- 
Necessity  of  ,.,..,  ,  ,     ,  1        -i 

saturation  with     ability  is  then  greatest  that  a  part  of   the  suboxide 

CuO.  will   be  precipitated.      This  is  accomplished  when 

cupric  sulphate  is  carefully  added  to  the  urine,  to 

super-saturation,   i.   e.,  the  carrying  out  of  Trommer's  test  exactly 

according  to  the  directions  given.     This  depends  on  the  following 

principle. 

Sugar  reduces  more  cupric  oxide  in  a  heated  solution  than  it  can 

in  the  cold.     The  maximum  formation  of  cupric  suboxide  and  the 


THE   UklNE.  33 

most  marked  reaction  is  obtained  when  so  much  cupric  sulphate  is 
added  that  the  resulting  precipitate  is  no  longer  entirely  dissolved  by 
shaking,  and  a  small  quantity  remains  undissolved.  The  urine  is 
then  super-saturated  to  a  slight  degree  with  cupric  oxide.  When 
heated,  all  the  cupric  oxide  in  solution,  together  with  the  undissolved 
portion,  will  be  reduced  to  cupric  suboxide  and  the  sugar  disappears. 
A  too  great  excess  of  copper  should  be  avoided  as  this  remains  after 
heating  unchanged,  a  dirty  green  cloudiness,  and  may,  if  the  quantity 
of  sugar  is  small,  prevent  the  precipitation  of  suboxide,  or  at  least 
hide  it.  Prolonged  boiling  converts  the  excess  of  copper  ( Vide  6) 
into  a  brownish-black  precipitate. 

9.     Normal  urine,  to  which  sugar  has  been  added,  and  some  speci- 
mens of  pathological  urine  may  contain  0.5  per  cent. 
of  sugar  and  not  show  a  precipitate  of  cupric  sub-        Difference  bcr 
oxide   when   treated  with    Trommer's   test,    which      tween  diabetic 
■^  f  TT-  1     r\  1  r        and  transitory 

precipitate  alone  {Vide  o),  proves  the  presence  of  glycosuria 

sugar.     In  typical  diabetic  urine,  however,  the  pre- 
cipitate forms  when   the  quantity  of  sugar   is   about   0.2   per  cent. 
Smaller  quantities  of  sugar  can  therefore  be  detected  in  diabetic  urine 
than  in  normal  urine  to  which  sugar  has  been  added. 

This  striking  phenomenon  is  explained  by  the  polyuria  which 
usually  exists  in  diabetes,  the  substances  capable  of  dissolving  cupric 
suboxide  being  relatively  much  diluted.  It  is  accordingly  often  pos- 
sible, in  cases  in  which  Trommer's  test  has  not  given  the  character- 
istic precipitate  of  cupric  suboxide,  to  obtain  this  by  repeating  the 
test  with  another  specimen  of  the  same  urine  diluted  with  several 
volumes  of  water  {i.  e.,  an  artificial  production  of  polyuria). 

Another  procedure  which  often  leads  to  the  desired  reaction,  is 
filtration  through  powdered  animal  charcoal,  freed  from  reducing 
substances  (sulphates,  ferric  protoxide  salts)  by  treatment  with  sul- 
phuric acid  and  water.  Put  some  of  this  charcoal  in  a  filter,  and 
drop  urine  upon  it  until  it  has  the  consistency  of  paste.  Make  a 
depression  in  the  centre  into  which  the  urine  is  gradually  poured. 
Then  examine  the  filtrate  by  Trommer's  test.  The  reaction  is  not 
made  more  delicate  by  this  filtration,  but  the  precipitate  of  cupric 
suboxide  can  be  more  easily  observed.  The  charcoal  removes  color- 
ing matters,  uric  acid,  and  also  small  quantities  of  sugar,  which, 
however,  makes  little  difference  in  the  qualitative  analysis. 

The  uncertainty  of  Trommer's   test   in   many   cases   may   induce 
3 


34  ^    CLINICAL  MANUAL. 

the  physician  to  discard  it,  and  to  use  one  of  the  other  tests  which 
are  more  reliable.  This  would,  however,  be  too  severe  a  condem- 
nation, as  Trommer's  test  has  always  this  advantage  for  the  physician, 
that  it  allows  an  approximate  estimation  of  the  quantity  of  sugar,  and 
thereby  of  the  severity  of  the  case.  If  the  reaction  is  easily  obtained, 
especially  by  insufficient  saturation  with  cupric  oxide,  the  quantity  of 
sugar  is  large,  and  the  case  is  one  of  advanced  diabetes.  If  the 
test  succeeds  only  by  exact  saturation  with  cupric  oxide,  or  if  the 
suboxide  is  not  precipitated,  while  more  sensitive  tests  give  positive 
results,  the  quantity  of  sugar  is  not  more  than  0.2-0.4  per  cent.,  and 
the  case  may  possibly  be  one  of  transitory  glycosuria. 

10.  Urine  containing  albumin  dissolves  cupric  oxide  (Biuret  re- 
action),   but   does   not   reduce   it.      Albumin   does   not ,  hinder   the 

reduction  of  cupric  oxide,  if  sugar  is  present,  but 
Presence  of  ,  /  ^  ^ 

albumin.  ^'  interferes  with  the  precipitation  of   cupric  sub- 

oxide. Therefore,  albumin  in  amount  over  0.2  per 
cent,  should  be  removed  (according  to  Nos.  9,  4,  or  11)  before 
the  test  for  sugar  is  made. 

3.  Fehling's  Test. — Fehling's  solution  is  made  by  mix- 
ing together  equal  parts  of  the  following  solutions  : 

(a)  34.64  grams  (534.5  grains)  of  pure  sulphate  of  copper  are 
dissolved  with  gentle  heat  in  water,  to  which  sufficient  is  afterwards 
added  to  make  500  c.c.  (16.8  ounces).  This  is  poured  into  a  tightly 
stoppered  bottle. 

(t>)  175  grams  (2700  grains)  of  Rochelle  salts  and  100  c.c.  (3I 
ounces)  of  caustic  soda,  having  a  specific  gravity  of  1.34,  are  dis- 
solved in  sufficient  water  to  make  500  c.c.  (16.8  ounces),  well  mixed, 
and  also  kept  in  a  well  stoppered  bottle. 

Qualitative. — If  a  qualitative  determination  alone 
is  desired,  some  of  the  test  solution  is  poured  into  a 
test-tube,  diluted  with  three  or  four  volumes  of  water, 
and  boiled  for  a  few  seconds.  If  the  solution  remains 
clear,  add  a  little  of  the  suspected  urine,  drop  by  drop. 
The  first  few  drops  of  ordinary  diabetic  urine  will 
usually  produce   a  yellow  precipitate.     If  a  volume  of 


THE    URINE.  35 

urine  equal  to  that  of  the  test  solution  be  added,  and 
the  mixture  boiled  without  a  precipitate  resulting,  sugar 
is  absent. 

If  a  precipitate  results  on  boiling  the  test  solution  alone,  a  little 
more  soda  should  be  added,  and  the  fluid  filtered,  after  which  it 
may  be  again  used.  It  is  better,  however,  to  make  up  a  fresh  solu- 
tion, when  an  accurate  analysis  is  desired. 

Quantitative. — The  principle  upon  which  this  test 
is  based  depends  upon  the  fact  that  grape  sugar  pos- 
sesses the  property  of  reducing  cupric  oxide  in  alkaline 
solution,  and  that,  when  all  the  copper  is  reduced,  the 
solution  loses  its  blue  color.  The  decolorization  of  a 
fixed  quantity  of  Fehling's  solution  by  a  known  quantity 
of  urine  allows  the  quantity  of  sugar  contained  in  the 
urine  to  be  readily  calculated,  as  lo  c.  c.  of  Fehling's 
solution  is  reduced  by  .05  gram  of  glucose. 

Procedure. — A  known  quantity  of  urine  is  diluted 
with  5  to  10  volumes  of  water.  Ten  c.c.  of  Fehling's 
solution  are  mixed  with  40  c.c,  of  water,  placed  in  a 
porcelain  dish  and  boiled.  The  diluted  urine  is  slowly 
added  with  a  pipette,  or,  preferably,  from  a  burette,  to 
the  diluted  Fehling's  solution,  kept  heated,  until  a  red 
or  yellow  precipitate  falls,  and  the  fluid  loses  its  blue 
color.  When  this  exact  point  is  reached,  sufficient  sugar 
(,05  gram)  has  been  added  to  reduce  the  copper.  From 
the  quantity  of  urine  required  to  produce  this  decolori- 
zation, the  percentage  of  sugar  contained  in  the  urine 
can  be  readily  calculated  ;  i  c,c,  =  5  per  cent,,  5  c,c.  = 
I  per  cent.,  etc.  It  is  often  very  difficult  to  know  exactly 
when  sufficient  urine  has  been  added.  The  precipitate 
should  at  times  be  allowed  to  settle,  and  the  color  of 
the  supernatant  fluid  noted.     If  it  is  bluish,  some  copper 


36  A    CLINICAL  MANUAL. 

remains  undissolved  ;  if  brownish,  too  much  urine  has 
been  added.  The  test  should  then  be  repeated  with 
greater  care,  but  in  spite  of  every  precaution  the  diffi- 
culty often  remains. 

4.  Worni-Miillers  Test  (Modified  Trommer  s  Test). — 
Reagents  Necessary  : 

(a)  Aqueous  solution  of  cupric  sulphate  (2.5  per  cent.). 

(b)  Solution  of  10  grams  (154  grains)  of  pure  neutral  tartrate  of 
soda  and  potash  in  100  c.c.  (3f  ounces)  of  normal  solution  of  caustic 
soda  (NaOH,  4  per  cent.). 

Procedure. — 5  c.c.  (rj  drachms)  of  urine  are  heated 
in  a  test-tube  to  the  boiling  point,  and  at  the  same  time 
a  mixture  of  2.5  c.c.  (40  minims)  of  solution  (b),  and 
I  to  2  c.c.  (15  to  30  minims)  of  solution  (a)  are  boiled 
in  another  test-tube.  Usually  1.5  grams  of  solution  (a) 
are  used.  If,  however,  the  specific  gravity  is  less  than 
1020,  it  is  advisable  to  use  only  i  c.c,  if  higher  than 
1025,  2  c.c.  should  be  used.  The  boiling  of  both  urine 
and  reagent  is  discontinued  at  the  same  time,  and  after 
20  to  25  seconds  they  are  mixed  without  shaking.  Im- 
mediately the  mixture  appears  bluish-green.  A  change 
then  occurs  if  sugar  is  present,  on  account  of  the  pre- 
cipitation of  cupric  suboxide  hydrate,  the  more  rapidly 
the  more,  sugar  present.  If  the  quantity  of  sugar  is  o.i 
per  cent.,  the  precipitate  generally  appears  after  4  to  5 
minutes  as  a  dirty  yellow  cloudiness  in  direct  light. 

A  precipitate  may  not  form  when  the  quantity  of  sugar  is  small, 
as  the  reaction  then  occurs  only  with  exact  quantities  of  copper. 
The  test  should  be  repeated  when  the  result  is  negative,  with  increas- 
ing quantities  of  the  solution  of  copper  (2.5,  3,  3.5,  4  c.c),  until 
the  reaction  ensues,  or  the  liquid  is  no  longer  discolored,  i.  e., 
until  it  remains  of  a  greenish  color,  an  evidence  of  an  excess  of  cop- 
per. This  test  permits  the  detection  of  .025  per  cent,  grape  sugar, 
or  ;05  per  cent,  milk  sugar  in  urine. 


THE    URtNE.  37 

Specimens  of  normal  urine  often  (i8  in  loo)  show  a  reaction  which 
indicates  the  presence  of  .025  to  .05  per  pent,  of  grape  sugar,  and 
which,  after  the  action  of  yeast,  cannot  be  obtained.  This  reaction, 
therefore,  can  be  due  to  no  other  substance  than  grape  sugar.  The 
reason  why  the  other  reducing  substances  give  no  reaction  with  this 
test  is,  besides  the  presence  of  the  tartrate  salt,  principally  the  keep- 
ing of  the  temperature  below  the  boiling  point.  To  accomplish  this, 
care  must  be  taken  to  allow  20  to  25  seconds  for  cooling,  before 
the  fluids  are  mixed.  The  grape  sugar  reduces  very  quickly  at  this 
temperature,  but  the  other  substances  do  not. 

5 .  Nylajiders  Bismuth  Test  (Modified  Bottgers  Test). 
Principle  of  the  reaction. — Add  to  an  aqueous 
solution  of  grape  sugar,  caustic  soda  and  a  little  bismuth 
subnitrate  NogBi  (0H)2,  then  boil  for  1-2  minutes. 
The  bismuth  salt  turns  black,  as  the  sugar  attracts  the 
oxygen  from  it,  and  is  converted  into  a  black  bismuth 
protoxide.  This  reaction,  discovered  by  Bottger  is,  in 
this  form  not  indicative  of  sugar  alone.  The  modifica- 
tion proposed  by  Nylander  is  more  accurate  and  reliable, 
as  few  other  substances,  and  these  occurring  rarely  in  the 
urine,  give  this  reaction. 

Reagent. — Four  grams  (i  drachm)  of  Rochelle  salts  are  dissolved 
in  100  c.c.  (3^  ounces)  of  a  moderately  warm,  8-per-cent.  solution  of 
caustic  soda  ;  2  grams  of  bismuth  subnitrate  are  added,  and  the  mix- 
ture shaken.  The  bismuth  salt  is  converted  to  bismuth  hydroxide  Bi 
(OH3)  by  the  caustic  soda,  and  this  is  dissolved  by  the  Rochelle  salts. 
The  reagent  when  cold  is  decanted,  if  necessary,  from  the  bismuth 
remaining  undissolved,  or  filtered  through  glass  wool.  It  preserves  its 
activity  for  some  time  when  kept  in  the  dark. 

Procedure. — Add  to  the  urine  the  reagent  in  the 
ratio  of  1:10  and  boil  for  1-3  minutes.  If  grape  sugar 
is  present,  the  bismuth  hydroxide  is  reduced,  and  is  con- 
verted into  a  black,  finely-divided  precipitate  of  bismuth 


38  A    CLINICAL  MANUAL. 

protoxide,  which  remains  suspended  for  some  time.  If  the 
urine  contains  .2  or  more  per  cent,  of  sugar,  the  black 
precipitate  forms  after  1-2  minutes,  and  is  so  marked 
that  the  urine  is  entirely  black.  If  the  amount  of  sugar 
is  less,  it  forms  after  prolonged  boiling  (3  minutes). 
Traces  of  sugar  (.025  per  cent.)  are  not  recognized  during 
the  heating  but  are  detected  by  the  grayish-black  color  of 
the  earthy  phosphates,  precipitated  by  the  caustic  soda. 
The  precipitate  of  the  phosphates  in  urine  free  from 
sugar  is  snow-white. 

Fourteen  of  100  specimens  of  normal  urine  treated  with  this 
reagent  showed  slight  reactions  which  could  not  be  obtained  after 
the  action  of  yeast.  These  reactions  must  therefore  have  been  due 
to  grape  sugar,  as  no  other  constituent  of  normal  urine-  shows,  with 
that  reagent  (yeast),  a  reaction  like  sugar.  Such  results  are  obtained 
only  when  Nylander's  reagent  is  made  exactly  as  directed  ;  the  caustic 
soda,  especially,  should  not  have  a  higher  concentration  than  indicated. 

Urine  after  the  ingestion  of  rhubarb  or  senna  reacts  to  Nylander's, 
but  not  to  Trommer's  test.  The  precipitated  bismuth  sinks  very 
quickly  to  the  bottom.  The  presence  of  large  quantities  of  rhubarb 
and  senna  is  shown  by  the  red  color  of  the  urine  upon  the  addition  of 
the  reagent  ;  smaller  quantities  are  detected  by  Heller's  haemoglobin 
test.  Urine  after  the  administration  of  salol  and  antipyrine  reacts  in 
the  same  manner.  It  is  possible  that  this  occurs  after  the  use  of  many 
other  medicines,  and  therefore  should  be  kept  in  mind. 

Albuminous  urine,  when  boiled  with  Nylander's  reagent,  becomes 
brownish-red  from  decomposition  of  the  albumin  and  the  formation 
of  bismuth  sulphide.  This  coloration,  if  the  quantity  of  albumin 
is  not  more  than  .2  per  cent.,  is  reddish-brown,  and  readily  distin- 
guished from  bismuth  reduced  by  sugar  ;  if  the  quantity  of  albumin 
is  larger,  it  is  brownish-black,  and  may  therefore  give  rise  to  confusion. 
For  this  reason,  the  albumin  should  first  be  separated  according  to 
No.  II. 

The  presence  of  ammonium  carbonate  (alkaline  fermentation)  may 
retard  the  reaction,  as  the  caustic  soda  of  the  reagent  is  converted 


THE  URINE.  39 

into  sodium  carbonate  and  ammonia  by  this  salt.  The  ammonia  vol- 
atilizes immediately  when  boiled,  and  cannot  therefore  maintain  the 
strong  alkalinity  necessary  for  the  reduction. 

6.  Fhenyl-Hydrazin  Test. — Heat  lo  c.c.  (2|  drachms) 
of  urine  with  0.5  c.c.  (7^  grains)  of  hydrochlorate  of 
phenyl-hydrazin  and  i.o  c.c.  (15  grains)  of  acetate  of 
soda  for  \  hour  on  a  water  bath.  If  sugar  is  present,  a 
precipitate  of  fine  yellow  needles,  a  combination  of 
phenyl-hydrazin  and  grape  sugar  (phenyl-glucosazon), 
forms  immediately  on  cooling  or  after  a  few  seconds. 
The  precipitate  should  be  abundant  (the  upper  part  of 
the  test-tube  filled  or  the  fluid  cloudy),  and  macroscopi- 
cally,  or  at  least  microscopically,  recognizable  as  formed 
for  the  most  part  of  yellow  needles  arranged  in  clusters 

(Fig.  5).^ 

7.  Fermentation  Test. — Saccharine  urine  is  fermented 
by  yeast,  and  the  sugar  converted  into  alcohol  and  car- 
bonic-acid gas;  CgHjgOg  =  2C2HgO -f- 2CO2.  The 
alcohol  remains  dissolved  in  the  urine,  the  carbonic-acid 
gas  escapes,  but  can  be  collected,  and  its  bulk  indicates 
the  quantity  of  sugar  present. 

As  no  other  normal  or  pathological  constituent  of  the  urine  gives 
a  similar  reaction  with  yeast,  this  test  is  accurate  and  also  sufficiently 
delicate  (to  o.  i  per  cent,  of  sugar).  The  fact  that  the  yeast  can  itself 
evolve  carbonic-acid  gas,  and  also  that  it  is  not  always  active,  neces- 
sitates a  control-test.  Furthermore,  the  result  is  known  only  after 
some  time.  This  test  is  therefore  recommended  if  those  previously 
mentioned  have  given  negative  results. 

Procedure. — This  test  is  easily  made  when  the  fer- 
mentation tube  or  saccharometer  (Fig.  6)  is  employed. 
Shake    thoroughly    together    in   a  test-tube   10  c.c.   (2.5 

^  For  illustration,  see  end  of  volume. 


40 


A    CLINICAL   MANUAL. 


drachms)  of  urine  and  i  gram  (15.4  grains)  of  compressed 

yeast  (or  -J-  of  a  cake  of  Fleisch- 
man's  yeast).  Pour  the  mix- 
ture into  the  bulb  of  the 
saccharometer,  inclining  it  so 
that  the  liquid  will  flow  into 
the  long  arm,  forcing  out  all 
the  air.  The  fluid  remains  in 
the  long  arm  due  to  atmospheric 
pressure.  The  tube  is  set  aside 
for  12-24  hours  in  a  room  at 
ordinary  temperature.  If  sugar 
is  present,  alcoholic  fermenta- 
tion soon  begins,  and  carbonic- 
acid  gas  collects  at  the  top 
of  the  long  arm^  driving  the 
liquid  up  into  the  bulb.  On  the 
following  day  the  height  of  the 
column  in  the  long  arm  shows 
the  displacement  of  the  liquid 
by  the  gas,  and  the  figures  in- 
dicate the  approximate  quantity 
of  sugar  contained  in  such  urine.  Urine  containing  a  large 
quantity  of  sugar  should  be  diluted  five  to  ten  times, 
and  the  result  multiplied  proportionately.  A  control- 
test  should  be  made  in  a  similar  tube  with  normal  urine 
and  yeast.  If  the  control-test  shows  a  small  bubble 
the  yeast  is  active.  A  few  drops  of  a  10  per  cent,  solution 
of  tartaric  acid  should  be  added  to  faintly  acid  or  alkaline 
urine  to  prevent  putrefaction,  which  is  injurious  to  the 
test. 

Method  of   Roberts. — An  approximate   estimation 
can  also  be  obtained  by  the  determination  of  the  specific 


FIG.  6. — einhorn's     sac- 
charometer. 


THE  UklNE. 


41 


gravity  before  and  after  alcoholic  fermentation.  This 
is  based  on  the  fact  that  diabetic  urine  undergoing 
fermentation  loses  in  specific  gravity.  Experiment  has 
shown  that  every  degree  in  specific  gravity  lost  in  fer- 
mentation corresponds  to  one  grain  of  sugar  per  fluid 
ounce.  Roberts  recommends  the  following  procedure  : 
about  4  ounces  of  the  saccharine  urine  are  placed  in  a 
i2-ounce  bottle,  and  a  lump  of  ordinary  yeast  about  the 
size  of  a  small  nut  is  added.  This  bottle  is  then  closed 
with  a  nicked  cork  to  permit  the  escape  of  the  carbonic- 
acid  gas,  and  placed  on  a  mantelpiece  or  other  warm  place. 
Beside  it  is  put  a  tightly  corked  4-ounce  vial,  filled  with 
the  same  urine  but  without  yeast.  In  18-24  hours  the 
fermentation  will  be  complete.  This  is  shown  when  the 
urine  has  become  more  transparent,  the  effervescence 
and  formation  of  foam  has  ceased,  and  the  greater  part 
of  the  yeast  has  sunk  to  the  bottom.  It  can,  however, 
be  definitely  determined  by  its  non-reaction  if  some  of 
the  urine,  taken  out  with  a  pipette,  is  subjected  to  one  of 
the  tests  for  sugar.  The  specific  gravity  of  the  decanted 
fermented  urine  is  taken  and  also  that  of  the  unfermented 
urine.  If  the  unfermented  urine  has  a  specific  gravity 
of  1030  and  the  fermented  urine  1020,  then  the  urine 
contains  10  grains  of  sugar  to  the  fluid  ounce. 

//  is  advisable  in  all  cases  not  entirely  clear ^  in  spite  of 
the  positive  result  in  the  reducing  tests^  to  deteri?iine  the 
presetice  of  grape  sugar  by  the  fermentation  test. 

8.  Indigo  Test. — Add  to  an  aqueous  solution  of  grape  sugar,  ren- 
dered strongly  alkaline  with  carbonate  of  soda,  a  solution  of  indigo 
carmine  (indigo  sulphate)  until  the  solution  is  distinctly  blue,  then 
boil.  The  color  changes  to  yellow,  and  becomes  blue  again  when 
shaken  up  with  air.  The  indigo  carmine  is  reduced  by  the  sugar,  and 
is  then  oxidized  to  indigo  blue  by  the  oxygen  of  the  air. 


42  A    CLINICAL  MAN  UAL. 

This  test  is  neither  especially  sensitive  nor  characteristic  of  grape 
sugar  in  urine.  The  test  papers,  sold  for  the  detection  of  sugar  in 
urine,  depend  on  this  reaction.  They  consist  of  strips  of  paper,  some 
of  which  have  been  saturated  with  a  solution  of  indigo  carmine,  others 
with  a  solution  of  soda  and  then  dried.  Place  a  strip  of  the  indigo 
paper  in  water,  add  this  blue  solution  to  the  urine  until  it  has  a  faintly 
blue  color,  then  put  in  the  fluid  a  large  strip  of  the  soda  paper  and 
boil.     If  sugar  is  present  the  change  in  color  as  above  occurs. 

21.  Glycuronic  Acid  (CeHioO,). — Its  presence  is 
ordinarily  of  little  clinical  importance,  but  as  it  may  be 
mistaken  for  sugar,  since  it  reacts  in  the  same  manner,  its 
occurrence  should  be  kept  in  mind.  Normally  it  occurs 
in  such  small  quantities  that  it  may  be  disregarded,  but 
after  the  ingestion  of  certain  substances,  as  camphor, 
turpentine,  kairin,  nitro-toluol,  chloral,  chloroform,  its 
quantity  may  be  so  greatly  increased  as  to  lead  to  error. 
In  such  cases  the  fermentation  test,  which  is  not  affected 
by  the  presence  of  glycuronic  acid,  should  be  employed. 

22.  Acetone  (CH3-CO-CH3). — A  volatile  fluid  having 
an  ethereal  odor  usually  present  in  urine  when  the  con- 
sumption of  albumin  is  increased  (diabetes,  fever,  meat 
diet,  and  starvation  in  health). 

I.  Legal' s  Test.-^^Kdd  to  urine  (one  drachm),  2  or  3 
drops  of  a  freshly  prepared  concentrated  solution  of 
nitro-prussic  soda  and  a  few  drops  of  caustic  soda.  The 
urine  becomes  purplish-red,  and  after  a  few  minutes 
changes  to  a  yellow  color.  Now  let  a  few  drops  of  con- 
centrated acetic  acid  carefully  flow  upon  it  without 
mixing.  If  acetone  is  present,  the  junction  of  the  fluids 
has  a  carmine  or  purplish-red  color,  and  after  some 
hours  becomes  a  dirty  bluish-green,  due  to  the  formation 
of  Prussian  blue.  The  characteristic  of  this  test  is  not 
the  red  coloration  in  alkaline  solution,  as  a  constituent 
of  normal  urine  (kreatinin)  shows  this  reaction,  but  the 
change  to  red  on  the  addition  of  acetic  acid. 


THE  VklNE.  43 

2.  Liebens  Iodoform  Test. — Two  grams  (30  grains)  of 
potassium  iodide  are  dissolved  in  6  c.  c.  (1.5  drachms)  of 
liquor  potassae  and  the  solution  boiled.  The  urine  is 
carefully  placed  on  the  surface  of  this  solution  in  a  test- 
tube.  At  the  plane  of  contact  a  precipitation  of  phos- 
phates occurs.  This  becomes  yellow  and  shows  crystals 
of  iodoform  if  acetone  is  present.  The  test  is  much  more 
certain  when  applied  to  a  distillate  of  the  urine  made  by 
evaporating  urine  to  which  a  small  qu-antity  of  phosphoric 
acid  has  been  added. 

23.  Di-AcETic  Acid  (CH3CO-CH2COOH).— It  is 
very  easily  converted  into  acetone  and  carbonic-acid  gas. 
It  reacts  to  Legal's  test  like  acetone,  and  in  aqueous  or 
ethereal  solutions  changes  on  addition  of  solution  of 
ferric  chloride  to  a  dark-red,  which  disappears  after  a 
time  when  an  acid  has  been  added  (Gerhardt's  reaction). 

Di-acetic  acid  is  present  in  the  urine  of  most  of  the 
severe  cases  of  diabetes  (always  in  diabetic  coma),  very 
rarely  in  high  fevers  and  nervous  disorders  of  adults, 
more  often  in  those  of  children. 

Determination  of  its  presence. — Add  to  urine  1-2 
drops  of  liquor  ferri  chloridi,  separate  by  filtration  the 
yellowish-white  precipitate  of  iron  phosphate,  and  add 
to  the  filtrate  more  of  the  solution  of  iron.  If  a  violet 
to  a  dark-red  coloration  appears,  the  presence  of  di- 
acetic  acid  is  probable.  Rhodan  oxide,  formic  acid, 
acetic  acid,  salicylic  acid,  the  products  of  kairin,  thallin, 
antipyrin,  etc.,  form  combinations  with  iron  showing  the 
same  color  reaction.  Two  control-tests,  with  a  fresh 
specimen  of  urine,  should  be  made  to  determine  abso- 
lutely its  presence.  Boil  one  portion  of  the  urine,  and 
when  cold  add  the  solution  of  iron  as  above.  The  red 
coloration  should  not  appear,  since  the  di-acetic  acid  is 
destroyed  by  boiling.     Acidulate  the  other  portion  with 


44  A    CLIMICAL  MANUAL. 

diluted  sulphuric  acid,  extract  with  ether,  and  add  a  few 
drops  of  the  solution  of  iron.  If  the  ether  assumes  a 
dark-red  color,  which  disappears  after  forty-eight  hours 
at  the  longest,  di-acetic  acid  is  present.  The  di-acetic 
acid  is  in  this  test  freed  from  its  salts  by  the  sulphuric 
acid  and  passes  into  the  ether. 

24.  Fat. — Small  quantities  of  fat  may  appear  in  the 
urine  after  the  consumption  of  an  excess  of  oleaginous 
food,  in  Bright's  disease  with  a  fatty  degeneration  of  the 
kidney,  in  cases  of  prolonged  suppuration,  phthisis,  and 
pyaemia,  in  diabetes  mellitus,  and  in  phosphorus  poison- 
ing. Its  presence  is  easily  detected  by  shaking  the  turbid 
urine  with  ether,  which  dissolves  the  fat  and  thus  clarifies 
the  urine.  The  fat  globules  may  also  be  recognized  by 
microscopic  examination  from  their  highly  refractive 
character. 

Chyle,  which  consists  of  lymph  cells  and  fat  globules  in  a  state  of 
minute  subdivision,  has  been  found  in  the  urine  in  a  disease  termed 
chyluria,  seen  almost  exclusively  in  the  tropics  and  due  to  the  pres- 
ence of  a  parasite,  filaria  sanguinis  hominis.  It  gives  to  the  urine  a 
milky  appearance. 

25.  Urea  CO  (NH2)2. — Urea  is  the  most  important  of 
the  products  of  nitrogenous  metabolism,  the  substances 
excreted  from  the  body,  and  of  which  nitrogen  forms  a 
constituent.  The  quantity  of  urea  eliminated  by  a 
healthy  adult  in  twenty-four  hours  ranges  from  32-40 
grms.  (493  to  616  grains),  but  it  varies  greatly  within 
physiological  limits,  and  much  more  in  morbid  con- 
ditions. 

The  chief  cause  of  this  variation  in  health  is  the  character  of  the 
food  ingested.  If  the  diet  contains  few  proteids  it  may  sink  to  from 
15-20  grms.  (231-308.6  grains).     If  it  is  rich  in  proteids  it  may  reach 


THE  URINE. 


45 


Z.  X 

-  s 

—  « 

— \Hi\ 


Q 


lOO  grms.  (1543  grains)  in  twenty-four  hours.  In  disease  its  excretion 
is  increased  in  fevers,  diabetes  mellitus,  diminished  in  diseases  of  the 
liver,  and  in  chronic  diseases  characterized  by  mahiutrition,  and  may 
entirely  cease  in  uraemia.  Its  quantity  is  as  a  rule  an  indication  of  the 
state  of  tissue  metabolism,  and  therefore  of  great  clinical  value.  A 
positive  deduction  in  regard  to  tissue  metabolism  can  only  be  made 
from  its  quantity  when  the  quantity  of  nitrogenous  compounds  in- 
gested with  the  food,  and  the  quantity  eliminated  by  other  channels, 
the  bowel,  the  skin,  and  the  lungs,  are  considered. 

Hypobromite  method. — An  approximate  estimate 
of  the  quantity  of  urea  is  easily  determined  by  this 
method  with  the  apparatus  designed  by  Doremus  (Fig.  7). 
This  method  is  based  upon  the  fact 
that  when  urea  is  oxidized  in  a 
strongly  alkaline  medium,  the  nitro- 
gen alone  remains  uncombined.  The 
quantity  of  nitrogen  evolved  indi- 
cates the  quantity  of  urea,  as  i  c.c. 
of  nitrogen  =  .0027  grm.  urea. 

Fill  the  long  arm  and  curve  of  the 
ureometer  with  the  hypobromite  so- 
lution, diluted  with  an  equal  volume 
of  water.  Draw  up  into  the  pipette 
I  c.c.  of  urine  (to  the  mark),  pass 
the  pipette  well  into  the  long  arm 
as  far  as  possible  and  compress  the 
nipple  gently  and  steadily,  forcing 
all  the  urine  into  the  hypobromite 
solution,  but  taking  care  no-t  to 
drive  any  air  after  the  urine. 
When  the  decomposition  is  com- 
plete, as  shown  by  a  cessation  of 
the  effervescence,  the  quantity  of  urea  can  be  read  off 
from  the  scale. 


FIG.  7. — doremus' 
UREOMETER. 


4-6  A    CLINICAL   MANUAL. 

The  hypobromite  solution  is  made  by  dissolving  lOO  grams  (1543 
grains)  of  caustic  soda  in  250  c.c.  (8.6  ounces)  of  water,  allowing  it 
to  cool  and  adding  25  c.c.  (63^  drachms)  of  bromine.  It  is  advisable 
to  make  up  only  a  small  quantity  when  required  as  the  solution  does 
not  keep.  A  mixture  of  the  urine  of  twenty-four  hours  should  be 
examined  as  the  quantity  of  urea  varies  markedly  at  different  times 
in  the  day. 

An  approximate  estimate  of  the  quantity  of  urea  usually  sufficiently 
accurate  for  clinical  purposes  can  be  made  from  the  specific  gravity 
of  a  mixture  of  all  the  urine  excreted  in  twenty-four  hours  in  almost 
all  cases  except  those  of  diabetes  mellitus.  Forty-six  hundredths  of 
the  total  solids  determined  by  multiplying  the  last  two  figures  of  the 
specific  gravity  by  2,33(Haser's  coefficient)  will  approximately  be  the 
quantity  of  urea  in  grams  in  1000  c.c.  of  urine. 

If  the  urine  contains  a  large  quantity  of  urea,  large  crystals  of  urea, 
often  visible  macroscopically,  are  formed  on  the  addition  of  nitric  acid. 

26.  Uric  Acid  (C5H4N4O3).  Uric  acid  is  also  a 
product  of  nitrogenous  metabolism,  and  is  excreted,  com- 
bined with  sodium  and  potassium,  in  the  urine  of  a 
healthy  adult  in  quantity  varying  from  0.5-.75  grams 
(7.5-10  grains)  every  twenty-four  hours. 

It  is  increased  in  health  by  an  abundant  meat  diet  and  in  disease  as 
fevers,  leukaemia,  pernicious  anaemia,  and  affections  of  the  heart  and 
lungs  characterized  by  dyspnoea.  It  is  diminished  in  a  number  of 
chronic  diseases  ;  nephritis,  arthritis,  diabetes,  and  especially  in  gout 
after  the  acute  paroxysm.  Certain  nervous  conditions,  neurasthenia, 
migraine,  chorea,  etc.,  are  said  by  Herter'  to  be  distinguished  by  an 
increase  in  the  ratio  of  uric  acid  to  urea. 

Its  presence,  when  free,  is  easily  recognized  by  microscopic  examina- 
tion, as  the  crystals  have  characteristic  shapes  and  are  always  yellowish- 
red  in  color  (Fig.  g). 

Murexide  Test. — Dissolve  a  little  of  the  urinary  sedi- 
ment with  a  few  drops  of  concentrated  nitric  acid  in  a 
porcelain  dish  by  heat  and  evaporate  carefully  to  dryness. 

^  "  The  Excretion  of  Uric  Acid,"  N.  Y.Med,  y^ournal,  Juuq  4, 
1892. 


THE  URINE,  47 

A  yellow  or  reddish-yellow  flake  remains  which  when 
moistened  with  a  trace  of  ammonia  becomes  a  rich  purple 
red,  with  caustic  soda  or  potash  a  beautiful  violet  or  blue. 
They  are  distinguished  from  xanthin  and  guanin  by  the 
disappearance  of  the  color  when  heated. 

Quantitative  estimation,  Heintz'  method. — Add 
5  c.c.  (ij  drachms)  of  hydrochloric  acid  to  loo  c.c. 
{^T^.^i  ounces)  of  urine.  Set  the  mixture  aside  for  twenty- 
four  hours,  then  collect  the  crystals  on  a  weighed  filter- 
paper,  wash  with  diluted  hydrochloric  acid,  dry  at  ioo° 
C.  and  weigh.  The  increase  in  weight  is  the  percentage 
of  urea.  In  some  cases  however  no  precipitate  is  ob- 
tained by  this  method. 

The  other  methods  are  so  tedious  and  complicated  as 
to  be  of  little  clinical  value. 

III. — Inorganic  Substances. 

27.  Sulphuretted  Hydrogen  (HgS). — The  common 
cause  of  hydrothionuria  is  the  decomposition  of  those 
normal  constituents  of  the  urine  which  contain  sulphur, 
due  to  special  bacteria  in  the  urinary  tract  (cystitis, 
pyelitis). 

If  the  urine  when  voided  shows  neither  indication  of  fermentation 
nor  cloudiness  due  to  bacteria,  an  extraneous  cause  is  to  be  thought  of 
(contamination  from  air,  pus,  or  the  intestines).  Urine  is  suitable  for 
examination  only  when  recently  voided,  as  sulphuretted  hydrogen 
may  be  present  on  account  of  fermentation  in  any  specimen  of  urine 
after  standing,  or  if  brought  from  a  distance  it  may  have  been  de- 
stroyed when  present  by  oxidation. 

Procedure. — A  current  of  air  is  forced  through  the 
urine  and  directed  by  means  of  a  small,  narrow  glass 


48  A    CLINICAL   MANUAL. 

tube  against  a  strip  of  paper  saturated  with  lead  acetate 
and  ammonia.  If  sulphuretted  hydrogen  is  present,  the 
paper  becomes  brown  or  black  in  a  few  minutes.  This 
coloration  is  due  to  the  formation  of  lead  sulphide.  The 
principle  is  the  reverse  of  that  of  the  syphon.  Air  should 
not  be  blown  through  for  more  than  ten  minutes,  as  in 
such  cases  HgS  may  be  formed  in  urine  which  did  not 
originally  contain  it. 

If  sulphuretted  hydrogen  is  present  in  krge  quantity,  the  paper  may 
be  fastened  in  the  neck  of  the  bottle  by  means  of  the  cork.  The  strip 
of  paper  becomes  brown,  at  least  at  the  edge,  after  the  bottle  has 
been  repeatedly  shaken  and  allowed  to  stand  for  a  few  minutes. 
Strips  of  filtering  paper  saturated  with  a  solution  of  acetate  of  lead 
should  be  kept  in  stock  and  moistened  with  ammonia  before  use. 

28.  The  Chlorides. — The  principal  chloride  found 
in  the  urine  is  sodium  chloride,  of  which  10-13  grams 
(154-200  grains)  are  excreted  daily.  Potassium,  ammoni- 
um, and  magnesium  chlorides  are  also  present,  but  in 
small  quantities. 

The  amount  of  the  chlorides  varies  with  the  quantity  of  salt  con- 
tained in  the  food  ingested  and  also  in  certain  diseases.  It  is  mark- 
edly diminished  in  acute  febrile  conditions  and  is  almost  entirely 
absent  in  croupous  pneumonia,  its  reappearance  indicating  improve- 
ment. It  is  increased  in  diabetes  and  in  some  forms  of  nephritis  with 
polyuria. 

Determination. — Acidulate  the  urine  strongly  with 
nitric  acid  and  add  a  few  drops  of  a  solution  of  nitrate 
of  silver.  If  the  chlorides  are  abundant  a  heavy  white 
precipitate  of  chloride  of  silver  forms,  if  present  in  small 
amount  only  a  milky  cloudiness  appears.  Other  silver 
salts,  especially  the  phosphate  of  silver,  are  dissolved  by 
the  nitric  acid. 


THE    URINE.  49 

29.  The  Sulphates. — They  appear  in  urine  as  simple 
sulphates  of  potassium,  sodium,  magnesium,  and  calcium, 
and  as  ethereal  sulphates.  Their  amount  varies  from 
1.5-3  grams  (23-46  grains),  depending  upon  the  food 
taken,  but  more  especially  upon  the  metabolism  of  the 
proteids.  Little  clinical  value  can  be  placed  upon  an 
increase  or  decrease  of  the  sulphates  in  disease. 

DETERMiNATiON.^^Acidulate  the  urine,  which  is  first 
filtered,  with  acetic  acid  and  add  a  solution  of  barium 
chloride.     A  white  precipitate  of  barium  sulphate  results. 

30.  The  Phosphates. — They  are  found  in  the  urine 
as  alkaline  phosphates  (sodium,  potassium,  and  ammo- 
nium) and  as  earthy  phosphate  (calcium  and  magnesium). 

As  phosphoric  acid  is  tri-basic,  it  forms  three  classes  of  salts — an 
acid,  a  neutral,  and  a  basic  salt.  The  alkaline  phosphates  are  sol- 
uble in  water  while  the  earthy  phosphates  vary  in  their  degree  of  sol- 
ubility, the  acid  (mono-)  phosphates  being  soluble,  the  neutral  (di-) 
phosphates  with  difficulty  soluble,  and  the  basic  (tri-)  phosphates 
almost  insoluble  (see  page  10).  The  quantity  of  phosphoric  acid 
excreted  in  the  urine  daily  ranges  from  2-3  grams  (31-46  grains).  It 
is  increased  in  inflammations  of  the  brain,  phthisis,  and  leukaemia  ; 
diminished  in  gout,  in  most  acute  diseases,  in  disease  of  the  kidney, 
during  pregnancy,  and  in  rachitis. 

Determination. — Render  the  urine  alkaline  with 
caustic  potash  or  ammonia  and  gently  heat.  A  flaky 
precipitate  of  earthy  phosphates  results. 

To  detect  the  alkaline  phosphates,  treat  the  urine  with 
ammonia,  then  filter.  Add  to  the  filtrate  a  mixture  of 
the  sulphates  of  magnesia  and  ammonia  which  precipi- 
tate the  phosphates  as  triple  phosphates. 

31.  The  Carbonates. — The  carbonate  of  soda,  lime, 
magnesia,  and  ammonia  are  usually  present  in  alkaline 
urine, 


50  A    CLINICAL   MANUAL. 

They  are  formed  from  the  carbonates  of  the  food,  also  from  the 
citrates,  malates,  and  tartrates  converted  into  carbonates  in  the  organ- 
ism. They  are  therefore  more  abundant  with  a  vegetable  diet.  The 
ammonia  salt  however  when  found  in  large  quantity  is  due  to  alka- 
line fermentation.  Urine  containing  carbonates  is  either  cloudy  when 
passed  or  soon  becomes  turbid  on  standing. 

Determination.— Urine  containing  carbonates  when 
treated  with  an  acid,  evolves  a  colorless  gas  which  ren- 
ders baryta  water  turbid. 

As  the  quantities  of  the  inoi'ganic  constitttents  of  the  urine 
depeiid  to  a  very  great  extent  upo?i_  the  character  of  the  food 
ingested^  quantitative  tests ^  which  are  tedious  and  complicated^ 
are  of  clinical  value  only  when  the  quantities  of  such  sub- 
stances contained  in  the  ingesta  and  absorbed  are  known. 

IV. — Accidental  Constituents. 

32.  Mercury. — Acidulate  250  c.c.  (8.5  ounces)  of 
urine  with  5  c.c.  {\\  drachms)  of  diluted  hydrochloric 
acid,  then  add  some  strips  of  tinsel,  which  are  acted 
upon  for  an  hour  at  a  temperature  of  6o°-8o°  C.  (140°— 
176°  F.).  The  tinsel  is  then  removed,  washed  with 
water,  alcohol,  and  ether,  dried,  placed  in  a  long,  narrow, 
dry  glass  tube,  and  heated  to  a  dull  red  heat.  The 
mercury,  which  has  formed  an  amalgam  with  the  tinsel, 
is  volatilized,  and  condenses  on  the  cooler  part  of  the 
tube  in  microscopically  small  globules.  If  after  cooling 
a  grain  of  iodine  is  placed  in  the  tube,  it  is  volatilized 
by  gentle  heat,  and  small  red  crystals,  as  if  spattered, 
become  visible,  due  to  the  formation  of  red  iodide  of 
mercury,     i  :  10,000  can  be  detected  by  this  method. 

2il.  Chlorate  of  Potassium. — Heat  the  urine  with 
^  its  volume  of  concentrated  hydrochloric  acid.     The 


THE  URINE.  51 

urine  assumes  first  a  reddish  to  violet  coloration,  due  to 
the  decomposition  of  the  indican  by  the  hydrochloric 
acid,  then,  if  chloric  acid  is  present,  it  becomes  either 
yellowish  or  colorless. 

One  part  in  10,000  maybe  detected  by  this  reaction.  The  chloric 
acid  is  freed  by  the  hydrochloric  acid  and  converted  into  chlorine, 
part  of  which  acts  on  the  pigment  of  the  urine,  and  part  escapes  as 
gas,  which  may  be  detected  if  in  any  quantity  by  its  odor  and  by  its 
action  on  a  piece  of  litmus-paper  held  in  the  mouth  of  the  test-tube. 

34.  Iodoform,  Iodine,  Iodides. — i.  Add  to  urine  a 
few  drops  of  starch-paste  (i  part  of  starch  boiled  with 
30-50  of  water),  and  pour  this  carefully  on  concen- 
trated, yellow  nitric  acid.  If  iodine  is  present,  a  transi- 
tory, deep-blue  ring  appears  at  the  junction  of  the 
fluids. 

One  part  in  100,000  can  be  detected  in  this  manner.  It  is  there- 
fore employed  as  a  test  of  the  absorbent  power  of  the  stomach,  as  the 
iodides  can  be  given  in  small  doses,  0.1-0.2  grams  (1^3  grains). 

2.  Add  to  urine  5-10  drops  of  concentrated,  yellow 
nitric  acid,  and  shake  the  mixture  with  1-2  c.c.  (10-20 
minims)  of  chloroform.  If  iodine  is  present,  the  chloro- 
form, which  has  sunk  to  the  bottom,  assumes  a  beautiful 
violet  color.  This  is  more  sensitive  than  the  previous 
reaction.  Iodine,  in  both  tests,  is  set  free  from  its  salts 
by  the  nitrous  di-oxide,  contained  in  the  yellow  nitric 
acid,  and  dissolves  in  the  chloroform  in  the  one,  or 
unites  with  the  starch  in  the  other.  Other  oxidizing 
agents,  chlorine  water  or  hypo-chloride  of  calcium,  may 
be  employed  in  place  of  the  nitric  acid. 

35.  Bromine  Salts. — Add  to  urine  either  a  few 
drops   of  a  solution   of  hypo-chlorite   of    calcium   and 


52  A    CLINICAL  MANUAL. 

hydrochloric  acid  or  chlorine  water,  then  shake  the 
mixture  with  i  c.c.  (lo  minims)  of  chloroform.  If  bro- 
mine is  present,  the  chloroform  assumes  a  yellow  colora- 
tion. Not  less  than  o.i  per  cent,  of  potassium,  sodium, 
or  ammonium  bromide  can  be  determined. 

36.  Carbolic  Acid. — The  urine  is  of  a  dark-green 
color  when  voided,  and  becomes  black  on  standing.  It 
does  not  react  to  the  common  tests  for  carbolic  acid,  as 
the  carbolic  acid  in  the  urine  is  combined. 

37.  Salicylic  Acid,  Salol,  Salicyluric  Acid. — 
Add  to  urine  a  few  drops  of  a  solution  of  ferric  chloride, 
if  the  urine  is  normal,  a  heavy,  yellow  precipitate  of  iron 
phosphate  forms,  if  salicylic  acid  is  present,  it  assumes 
an  intensely  violet  coloration  (compare  23,  di-acetic 
acid).  If  the  quantity  is  very  small  (i  :  12,000),  acidu- 
late the  urine  with  hydrochloric  acid,  and  shake  with 
ether,  in  which,  diluted  with  water,  the  reaction  will 
appear  on  the  addition  of  the  solution  of  iron. 

These  substances  may  be  employed  to  determine  gastric  absorption 
in  the  same  manner  as  iodide  of  potassium,  because  of  their  easy 
detection  and  innocuousness  in  small  doses. 

This  reaction  occurs  only  if  the  solution  of  ferric  chloride  is 
neutral,  as  free  hydrochloric  acid  decomposes  the  salicylate  of  iron. 
Phenol  acts  in  the  same  manner. 

38.  Tannin  (Di-Gallic  Acid). — It  appears  in  the 
urine  partly  as  gallic  acid.  Both  acids,  when  treated 
with  solution  of  ferric  chloride,  assume  a  dark-blue  or  a 
bluish-black  coloration,  with  alkalies  they  become  brown, 
due  to  their  oxidation. 

39.  Chrysophanic  Acid. — It  appears  in  the  urine 
after  the  administration  of  chrysarobin,  rhubarb,  or 
senna.      Alkalies  color  such  urine  red,  and    lime-salts 


THE  URINE.  53 

form  a  red  precipitate.  Differentiate  it  by  means  of 
ether  from  the  pigment  after  the  use  of  santonin,  which 
acts  in  a  similar  manner.  The  chrysophanic  acid 
passes  into  the  ether,  and  gives  a  red  coloration  to  it  on 
the  addition  of  caustic  soda. 

40.  Balsam  of  Copaiba. — After  its  use  the  line  of 
polarization  is  deflected  to  the  left,  and  the  urine  can 
reduce  cupric  oxide,  but  not  bismuth  oxide.  When  a 
mineral  acid  is  added,  it  becomes  cloudy  from  the  pre- 
cipitation of  resinous  acids,  and  immediately  assumes  a 
purplish-red,  then  a  violet  color.  Heat  and  an  oxi- 
dizing agent,  e.  g.  hypo-chlorite  of  calcium,  produce  this 
reaction. 

41.  Alkaloids. — These  form  with  acetic  acid  and 
the  solution  of  potassio-mercuric  iodide  precipitates 
distinguished  from  albumin,  peptone,  and  mucus  by 
their  solubility  in  alcohol.  The  detection  of  the  differ- 
ent alkaloids  requires  more  complicated  methods  than 
can  be  given  here. 

V. — Urinary  Deposits. 

The  urinary  deposits  may  be  either  unorganized, 
chemical  substances,  as  uric  acid,  urates,  phosphates, 
etc.,  or  organized,  anatomical  elements,  as  blood  cells, 
mucus,  casts,  etc.  The  methods  for  their  examination 
are  chemical,  microscopical,  and  micro-chemical.  The 
deposits  are  obtained  in  several  ways. 

42. — I.  If  the  urine  has  been  standing,  pour  off  the 
clear  supernatant  fluid  and  allow  the  remainder  to  settle 
for  twelve  hours  in  a  conical  glass  or  test-tube.  Remove 
a  little  of  the  sediment  with  a  pipette,  introducing  it  wath 
its  upper  opening  closed  by  the  forefinger  into  the  sedi- 


54 


A    CLINICAL    MANUAL. 


ment,  then  raise  the  finger,  allowing  some  of  the  sediment 
to  enter  the  tube  and  replace  the  finger  on  its  removal. 
Allow  the  urine  on  the  outside  to  run  off,  and,  by  moving 
the  finger,  place  the  desired  amount  of  sediment  on  a 
slide,  cover  with  a  glass,  and  examine  under  a  micro- 
scope. 

2.  If  an  immediate  examination  of  the  sediment  is 
desired  for  diagnosis^  or  if  an  earlier  examination  on  ac- 
count of  the  rapid  decom- 
position of  urine  in  sum- 
mer^ is  necessary,a  deposit 
of  the  sediment  may  be 
quickly  produced  by  the 
use  of  the  Litten  centrifu- 
gal machine^  (Fig-  8). 
Test-tubes  made  of  glass 
thicker  than  usual  and 
with  conical  bottoms 
should  be  used.  They 
are  filled  with  urine, 
placed  in  the  holders, 
and  rotated  for  three 
minutes.  All  the  sedi- 
ment is  thrown  to  the 
bottom,  and  usually  ap- 
pears as  a  turbidity  or  dense  crust. 

3.  Another  method  for  rapidly  obtaining  the  sediment 
is  by  electrolysis.^     Pieces  of  iron  wire  are  attached  to 

^  Otherwise  the  urine  should  be  treated  with  an  antiseptic,  thymol 
or  salicylic  acid,  and  kept  in  a  cool  place. 

^  Sold  by  J.  T.  Dougherty,  411  West  Fifty-ninth  Street,  New 
York  City. 

^  Centralblatt  fiir  klinische  Medicin,  January  7,  1893. 


FIG 


5. — THE    LITTEN    CENTRIFU- 
GAL   MACHINE. 


THE  URINE.  55 

the  poles  of  a  battery,  consisting  of  two  zinc-carbon 
elements,  and  inserted  some  distance  apart  through 
the  cork  bottom  of  a  cylinder  filled  with  urine. 
The  oxygen  and  hydrogen  from  the  decomposition  of 
water,  which  is  continued  for  five  to  ten  minutes, 
carry  up,  as  they  arise,  all  the  sediment  of  the  urine 
and  this  is  held  in  the  foam  at  the  top  of  the  column  of 
urine.  A  little  of  the  lower  surface  of  the  foam,  where 
the  urinary  constituents  are  held,  should  be  removed  with 
a  pipette.  This  method  has  not  given  results  as  satis- 
factory as  either  of  the  other  methods. 

I.— UNORGANIZED  SEDIMENT. 

A. SEDIMENT    OF    ACID    URINE. 

43.  Uric  Acid. — Uric  acid  occurs  in  crystals  of  a 
reddish-yellow  or  reddish-brown  color,  due  to  the  urinary 
pigment.  The  crystals  vary  in  shape  and  size,  and  can 
often  be  recognized  by^the  unaided  eye  as  sand,  gravel, 
etc.  The  basis-shape  is  the  rhombic  plate,  which  may 
become  hexagonal,  or  most  commonly  elliptic,  like  a 
whetstone.  They  may  also  resemble  rosettes,  sections  of 
a  barrel,  balls,  and  crystals  of  the  most  irregular  shape, 
with  striated  spicules  (Fig.  9) — all  characterized  by  their 
color,  and  by  it  alone  readily  recognized.  The  very 
irregular  crystals  are  due  to  the  rapid  precipitation  of 
uric  acid,  especially  where  there  is  a  great  tendency  to 
concentration  of  urine  and  therefore  a  predisposition  to 
the  formation  of  stone. 

44.  Urates, — A  yellow-  or  brick-red  amorphous 
sediment  (sedimentum  lateritium),  which  often  adheres 
strongly  to  the  vessel,  consists  of  the  acid  urates  (urates 


56 


A    CLINICAL    MANUAL. 


of  the  general  formula,  C5H3N4O3M),  principally  urates 
of  soda,  and  usually  also  of  some  uric  acid.  It  is 
characterized  by  its  complete  solubility  when  the  urine 
is  warmed.  The  urates  appear  under  the  microscope  as 
fine  granules,  in  heaps  or  like  moss,  and  reflect  no  color. 

CHEMICAL    REACTION    OF    URIC    ACID    AND    URATES. 

I.  The  urates  are  readily  dissolved  by  heat,  even  before 
the  solution  boils. 


FIG.  9. — URIC-ACID  CRYSTALS. 


2.  The  urates  are  dissolved  on  the  addition  of  acetic 
acid,  and  large  crystals  of  uric  acid  (usually  quadratic 
or  rhombic  plates)  appear  after  a  time  in  their  place. 

3.  Uric  acid  is  dissolved  slowly  in  warm  water,  rapidly 
even  in  the  cold,  on  the  addition  of  alkalies  (caustic 
soda). 

4.  Urates  and  uric  acid  react  to  the  murexide  test 
(Art.  26). 


THE  URINE, 


5; 


45.  Oxalate  of  Lime,  CaC204. — These  crystals 
have  been  found  in  small  quantity  in  normal  urine. 
Their  number,  however,  is  often  markedly  increased 
after  the  ingestion  of  tomatoes,  asparagus,  beet  root, 
fresh  beans,  etc.,  vegetables  containing  much  oxalic  acid, 
and  in  conditions  of  mal-nutrition. 

They  settle  very  slowly  on  account  of  their  lightness, 
and  are  therefore  often  overlooked. 

Microscopical  appearance. — They  appear  in  two 
forms. 

1.  Transparent,  strongly  refracting  octahedral  crystals 
(envelope     shape), 

less  often  short  or 
long  prisms  with 
pyramidal  ends, 
(combination  o  f 
the  octahedral 
shape  and  the  prism, 
Fig.  10).  The  per- 
f  e  c  t  octahedral 
crystals  are  charac- 
teristic of  calcium 
oxalate  ;  the  other 
shapes  may  be  con- 
founded with  am- 
monio  -  magnesium 
phosphate. 

2.  Round  or  oval  disks,  having  a  central  contracture 
(sand-clock,  dumb-bell,  or  spheroid  shape.  Fig.  10). 
These  unusual  shapes  are  not  characteristic,  and  may  be 
confused  with  calcium  carbonate,  uric  acid,  or  ammonium 
urate. 

Chemical  reaction.  —  Insoluble  in  acetic  acid, 
readily  soluble  in  mineral  acids  (hydrochloric  acid). 


FIG.     10. — CALCIUM-OXALATE     CRYSTALS. 


58 


A   CLINICAL  MANUAL. 


B. — SEDIMENT    OF    SLIGHTLY   ACID   (aMPHOTERIC)  URINE. 

46.     Di-Calcium  Phosphate  (neutral  phosphate  of 
lime,  CaHP04  +  2  HgO). — An  uncommon  sediment. 
Wedge-shaped    crystals,    arranged    in    the    form    of 

sheaves  or  rosettes,  Fig. 
II.  They  are  often  very 
small,  and  so  crowded  to- 
gether that  their  struc- 
ture is  recognized  with 
difhculty.  Decomposed 
by  ammonia,  and  very 
soluble  in  acetic  acid. 


FIG.  II. — DI-CALCIUM-PHOSPHATE 
CRYSTALS  (jAKSCH). 


47.  Ammonio-Magnesium  Phosphates. — {Vide \()?^ 

C. SEDIMENT    OF    ALKALINE    URINE. 

48.  Earthy  Phosphates. — Tri-calcium  and  tri- 
magnesium  phos- 
phates, Cag  (P04)2 
and  Mg3  (POJ2. 
Small  amorphous 
granules  occurring 
singly  or  in  trans- 
parent, ill-defined 
groups.  Very  solu- 
ble in  acetic  acid. 

49.  Ammonio- 
Magnesium  Phos- 
phate (triple  phos- 
phates, NH^Mg 
PO4  +  6  HgO).— 
Large  three-,  four-, 
or  six-sided  prisms,  fig.  12. — triple  phosphates. 

with  bevelled  ends  (cofhn-lid  shape)  ;  they  may,  how- 


THE  URINE. 


59 


ever,    exhibit    very    irregular   shapes    and    have   jagged 
edges  (Fig.  12).     A  common  sediment  in  alkaline  urine, 
readily  soluble  in  acetic  acid. 
50.     Ammonium 

Urates. —  Large,        Vr-<.  1/      fe  f^      V^ 

11        ^11  k       f       ^fe-J      4\^t 

usually     dark-yel-        ^*        J  V^*:/         yV; 

low,  spherical 

bodies,  singly  or 
in  groups,  and 
usually  beset  with 
radiating  spic- 

ules (thorn-apple 
shape) ;  rarely  large 
balls  (Fig.  13). 

A  common  sediment  in  alkaline  fermentation,  soluble 
in  acetic  acid,  with  the  formation  of  crystals  of  uric 
acid  ;  soluble  with  difficulty  in  water. 

Oxalate  of  calcium  {vide  45)  and  other  constituents 
of  acid  urine  (uric  acid,  urates)  may  be  found  if  the 
reaction  becomes  alkaline  after  their  precipitation. 
Such  sediment  persists  for  a  long  time  when  enclosed  in 
mucus,  which  retards  the  equalization  of  the  reaction. 


AMMONIUM-URATE    CRYSTALS. 


D. UNCOMMON    URINARY    DEPOSIT. 


FIG.  14. — CALCIUM  SULPHATE  (jAKSCH). 


51.  Sulphate  of 
Calcium,  CaS04  + 
2  HgO. — Long  prisms 
or  plates,  with  sharply 
cut  ends,  singly  or  in 
groups  (Fig.  14).  In- 
soluble in  acetic  acid, 
soluble  with  difficulty 
in  mineral  acids  and 
in  water. 


6o 


A    CLINICAL   MANUAL. 


52.  Carbonate  of  Calcium,  Ca  C03. — Amorphous 
or  crystallized  in  groups  of  granules  or  small  iridescent 
flakes  on  the  surface  of  the  urine  (Fig.  15). 

Very  soluble  in  acetic  acid  with 
the  evolution  of  carbonic-acid  gas. 
The  normal  sediment  in  the  urine 
of  vegetarians. 

53.    Crystalline  Tri-Magne- 
siUM  Phosphate,  Mgg  (P04)2  + 
22  HgO. — Long,  smooth,  strongly 
refracting,  rhomboidal  plates,  very 
soluble  in  acetic  acid. 
54.    Cystin. — Colorless,  symmetrical  hexagonal  plates. 
Insoluble  in  acetic  acid,  soluble  in  mineral  acids,  alka- 
lies, and  also  in  ammonia,  which  distinguishes  it  from 
uric  acid. 

Leucin  and  Tyrosin. — Often  present  in   acute 


FIG.    15. — CALCIUM  CAR 
BONATE  (JAKSCH). 


55- 


yellow  atrophy  of  the   liver  and  in  phosphorus  poison- 
ing ;    seldom     in 

cco      o 


& 


severe  cases  of 
typhoid  fever,  va- 
riola, and  perni- 
cious anaemia. 

Leucin  is  moder- 
ately soluble  in  water, 
and  crystallizes,  when 
pure,  in  delicate 
flakes;  when  impure, 
in  balls  and  amor- 
phous masses,  formed 
of  groups  of  flakes 
(Fig.  t6).  They  are 
distinguished  from  fat  by  their  inferior  light  refraction  and  their  in- 
solubility in  ether,  from  ammonium  urate  by  their  action  with  acids. 


FIG.   16. — leucin   and   tyrosin. 


THE  UR2NE. 


6i 


Tyrosin  is  with  difficulty  soluble  in  cold  water,  but  is  more  solu- 
ble in  acids  and  alkalies.  It  crystallizes  in  tufts,  sheaves,  or  balls, 
formed  of  very  fine  needles  (Fig.  i6),  and  assumes  a  beautiful  red 
coloration  when  heated  with  Millon's  reagent  (a  mixture  of  equal 
parts  of  mercury  and  nitric  acid,  diluted  with  twice  its  bulk  of  water 
and  then  after  some  hours  separated  by  filtration  from  the  precipitate 
formed). 


Leucin  very  rarely,  tyrosin  seldom,  appears  as  a  sedi- 
ment in  urine.  Either,  however,  may  in  most  cases  be 
obtained  if  the  urine  is  concentrated  by  heat,  or  treated 
with  acetate  of  lead,  and  the  filtrate  freed  from  lead  by 
sulphuretted  hydrogen  and  concentrated.  The  pre- 
cipitate is  recognized  by  its  microscopic  and  chemical 
character. 

56.  HipPURic  Acid. — The  crystals  have  the  form  of 
needles  or  rhomboidal 
prisms  (Fig.  17).  They 
may  be  confounded  with 
ammonio  -  magnesium 
phosphate  or  uric  acid  ; 
from  the  former  they  are 
distinguished  by  their  in- 
solubility in  acetic  acid? 
from  the  latter  by  the 
failure  of  the  murexide 
test. 

Bilirubin. — Amorphous  yellow  granules,  needles, 


fig.  17. — hippuric  acid 
(jaksch). 


57- 


or  plates,  found  in  pus-cells  or  fat  globules, 
caustic  soda. 


Soluble  in 


58.       HEMOGLOBIN 

in  casts. 


Amorphous  or  crystalline  found 
59.     Fat. — Strongly  refracting   globules   of   varying 


62  A    CLINICAL    MANUAL, 

size,  readily  soluble  in  ether.  Gives  off  an  odor  like 
acrolein  (acrylic  aldehyde)  when  heated  on  a  platinum 
foil. 

In  lipuria  fat  alone  is  present,  in  chyluria  albumin  is 
also  found  in  the  urine.  They  are  by  this  difference 
easily  distinguished  from  each  other. 

2.— ORGANIZED  SEDIMENT. 

60.  Mucus. — It  occurs  normally  in  urine  partly  dis- 
solved and  partly  as  a  marked  turbidity  which  sinks  to 
the  bottom  as  a  heavy  cloud,  but  in  catarrhal  conditions 
of  the  urinary  passages  its  quantity  is  greatly  increased. 
Under  the  microscope  it  is  transparent,  and  recognized 
only  by  the  elements  embedded  in  it  (urates,  epithelial 
cells,  leucocytes,  etc.).  The  ribbon-shaped  mucous 
threads  have  a  distant  resemblance  to  urinary  casts. 
The  addition  of  diluted  acetic  acid  to  mucus  produces  a 
fiocculent  precipitate,  not  soluble  in  an  excess  of  the 
acid,  or  on  application  of  heat.  Mucus  disappears  al- 
most completely  on  the  addition  of  caustic  soda.  This 
reaction  distinguishes  it  from  pus. 

61.  Pus  (Leucocytes). — A  few  leucocytes,  granular 
masses  of  protoplasm  with  nuclei,  may  be  present  in 
normal  urine,  but  an  increased  quantity  indicates  a  sup- 
purative condition  of  some  part  of  the  urinary  tract,  as 
urethritis,  cystitis,  pyelitis,  abscess,  tuberculosis.  In 
women,  however,  pus  found  in  the  urine  may  be  derived 
from  the  vaginal  secretion.  If  pus  is  present  in  any 
quantity,  a  yellowish  sediment  forms.  Leucocytes  can 
generally  be  recognized  by  the  microscope  (Fig.  18)  ; 
in  acid  or  neutral  urine  they  preserve  their  form,  while  in 
alkaline  urine  (alkaline  fermentation)  they  swell  up  into 


THE  URINE. 


63 


FIG.  18. — LEUCOCYTES. 

I,  Leucocytes  treated  with 
acetic  acid. 


a  formless,  glairy  mass,  due  to  the  action  of  the  ammonia. 
The  addition  of  iodo-potassic-iodide  solution  distin- 
guishes them  from  forms  of 
epithelial  cells  when  there 
is  doubt,  the  leucocytes  be- 
coming a  deep  mahogany- 
brown,  the  epithelial  cells  a 
light  yellow.  The  addition 
of  I  per  cent,  acetic  acid  is 
usually  necessary  to  make 
visible  the  nuclei.  If  liquor 
potassse  is  added  to  a  de- 
posit of  pus,  it  is  converted  into  a  viscid  gelatinous 
mass  (Donne's  test).  Urine  containing  pus  always 
exhibits   the   reactions  for  albumin. 

62.  Red  Blood  Cells. — They  are  found  as  a  morbid 
element  in  the  urine,  and  may  vary  in  quantity  from  a 

few  cells  seen  with  difli- 
(QQ    ©  culty  by  the  microscope 

to  a  mass  easily  recog- 
nized by  the  unaided  eye. 
In  fresh  acid  urine  they 
are  of  normal  size,  shape 
and  color,  but  they  soon 
undergo  a  change,  be- 
coming either  larger  and 
swollen  or  contracted  and 
crenated.  Theynevertake 
on  an  appearance  like  that 
of  a  roll  of  coins  (Fig. 
19).  After  a  time  they  lose  their  sharp,  regular  outline, 
and  in  ammoniacal  urine  are  soon  dissolved  (see  page  19). 

63.  Epithelial  Cells. — They  occur  in  small  num- 


FIG.  19. — RED  BLOOD  CELLS. 

.1,  Normal  blood  cells  ;  2,  swol- 
len blood  cells  ;  3,  shrunken 
blood  cells. 


64 


A    CLlNiCAL    MANUAL. 


bers  in  normal  urine,  but  are  much  increased  in  numbers 
in  certain  pathological  conditions — irritation  or  inflam- 
mation of  any  part  of  the  urinary  tract.  They  are  masses 
of  protoplasm,  larger  than  leucocytes,  having  single 
nuclei,  visible  without  treatment  with  acetic  acid,  and 
more  or  less  granular  in  structure  (Fig.  20).  They 
have  at  times  been  confounded  with  leucocytes,  but 
their  polygonal  shape  and  single,  large,  round,  or  oval 
nucleus  usually  renders  the  differentiation  easy.  Though 
their  shape  is  characteristic  of  the  part  of  the  urinary 


FIG.  20. — EPITHELIAL   CELLS. 

From  (a)  the  uriniferous  tubules,  (b)  the  pelvis,  (c)  the  bladder,  (d) 
the  ureter,  (e)  the  prostate,  (f)  the  male  urethra,  (g)  female  urethra, 
(h)  vagina. 

tract  from  which  they  come,  it  is  usually  difficult  to  de- 
termine exactly  their  origin,  as  many  are  very  similar, 
and  the  appearance  of  others  may  be  much  affected  by 
maceration  in  the  urine.  The  following  shapes  are  easily 
distinguished  : 

Origin. 

1.  Round — Uriniferous  tubules. 

2.  Caudate — Pelvis  of  the  kidney,  ureter,  male  urethra. 

3.  Large  polygonal — Bladder,  female  urethra,  vagina. 


THE  URINE. 


65 


64  Casts.— These  are  moulds  of  renal  tubules,  and 
occur  in  the  urine,  with  a  few  exceptions,  only  in  disease 
of  the  kidney  and  with  albuminous  urine.  They  are 
formed  from  proteids  coagulated  in  the  tubules,  the  pro- 
teids  having  been  allowed  to  pass  from  the  blood  mto  the 
tubules  on  account  of  a  morbid  condition  of  the  epi- 
thelial cells.  These  moulds  block  up  the  tubules  until 
the  pressure  of  the  urine  from  behind  is  sufficient  to 
carry  them  out  into  the  urine.     They  are  divided  into  : 


FIG.   21. — CASTS. 

A,  Hyaline  casts  ;  B,  hyaline  casts  with  leucocytes  ;  C,  epithelial 
cast';  D,  granular  cast ;  E,  waxy  cast  ;  F,  blood  cast. 

a.  Epithelial  Casts.— Produced  by  the  coagulation 
of  blood  plasma,  which  has  escaped  into  the  tubules. 
They  are  covered  more  or  less  completely  with  the 
degenerated  epithelium  (Fig.  21). 

b  Blood  Casts.— Casts  of  tubes  into  which  a  hem- 
orrhage has  taken  place.  They  may  contain  only  en- 
tangled blood  cells,  or  at  times  may  seem  to  be  formed 
entirely  of  blood  cells  (Figs.  19  and  21). 

c.  Granular  Casts.— Fhey  are  usually  of  variable 


(£  A    CLINICAL    MANUAL. 

size  and  imperfect  form.  The  granulation  may  be  very 
fine,  or  less  often  somewhat  coarse,  and  their  color  varies 
from  a  pale-yellow  to  a  reddish-brown.  Leucocytes,  fat 
globules,  and  crystals  may  occasionally  be  seen  upon 
them.  They  are  probably  formed  from  the  debris  of 
degenerated  epithelial  or  blood  cells  (Fig.  21). 

d.  Hyaline  Casts. — Pale,  transparent,  almost  struc- 
tureless forms,  detected  with  great  difficulty.  They  are 
the  coagulated  products  of  the  exudation  of  blood  plasma 
into  the  tubules.  They  are  of  larger  size  when  formed 
in  tubules  previously  stripped  of  epithelium.  They  may 
also  occasionally  be  formed  from  the  secretion  of  the 
epithelium  lining  the  tubules,  and  thus  not  indicate 
severe  renal  disease  (Fig.  21). 

e.  Waxy  Casts.  —  Characterized  by  their  greater 
length,  and  when  short  by  their  great  breadth.  Under 
the  microscope,  they  appear  homogeneous,  strongly  re- 
fractive, and  often  segmented.  Fat  globules,  epithelial 
cells,  blood  cells,  fungi,  and  various  crystals  may  fre- 
quently be  seen  upon  their  surface.  They  are  dis- 
tinguished from  hyaline  casts  by  their  strongly  refractive 
character  and  their  great  resistance  to  acids.  Their 
formation  is  probably  due  to  a  degeneration  of  the 
epithelium  and  exudation  of  morbid  products  (amyloid 
material,  fibrin)  (Fig.  21). 

f.  Urate  Casts. — Crystals  of  urate  of  soda  may  as- 
sume the  form  of  the  tubule  into  which  they  are  excreted. 
They  dissolve  on  the  application  of  heat.  They  have 
been  found  in  cases  of  gout  and  renal  congestion,  but  do 
not  necessarily  indicate  severe  renal  disease. 

The  great  diagnostic  importance  of  the  presence  of  casts  in  the 
urine  depends  upon  the  fact  that  they,  with  a  few  exceptions,  indi- 


THE  URINE.  6j 

cate  renal  disease.  Hyaline  casts  have  often  been  found  in  catarrhal 
icterus  and  also  at  times  in  the  urine  in  cases  of  fever,  severe  anaemia, 
leukaemia,  and  diabetes  without  renal  complication.  But  the  presence 
of  blood,  epithelial,  granular,  or  waxy  casts,  is  always  of  serious  sig- 
nificance. The  casts  are  usually  the  more  numerous  the  greater  the 
quantity  of  albumin  and  the  more  severe  the  disease,  although  there 
are  many  exceptions  to  this.  The  casts  often  appear  in  the  beginning 
of  a  nephritis  before  albuminuria  is  detected  and  usually  in  the  re- 
covery of  acute  nephritis  continue  after  the  albumin  has  disappeared. 

It  at  times  happens  that  casts  are  not  found  in  cases  of  renal  albu- 
minuria, because  a  sufficiently  careful  search  has  not  been  made.  In 
suspected  cases,  several  slides  should  be  thoroughly  examined  before 
a  positive  conclusion  is  drawn.  A  magnifying  power  of  at  least  one 
sixth  objective  should  be  used  in  the  examination  for  casts  ;  it  saves 
time,  however,  to  first  look  over  the  slide  with  a  lower  poM^er,  and 
then  to  examine  more  closely  with  a  higher  power  all  suspected 
objects. 

Various  accidental  constituents,  as  fibres  of  cotton,  linen,  and 
wool,  and  hair,  may  be  mistaken  for  casts.  They  are  distinguished 
by  their  general  appearance  and  the  character  of  their  ends,  which 
are  generally  square  or  broken  and  ragged,  while  those  of  casts  are 
more  or  less  round,  even,  and  smooth. 

65.  Spermatozoa. — They  are  about  50  }x  in  length 
(7  times  the  diameter  of  a  red  blood-cell),  and  consist 
of  a  pear-shaped  head  and  a  long  tapering  tail.  They 
may  be  found  in  the  urine  after  coitus  and  emissions, 
and  in  the  vaginal  secretion  after  connection. 

dd.  Fragments  of  Tumors. — They  are  very  rarely 
seen  in  the  urine,  and  are  of  no  practical  clinical  value 
on  account  of  the  difficulty  involved  in  their  recognition, 

67.  Micro-Organisms  (fermentative  and  pathogenic 
fungi), — Healthy  urine  when  voided  is  free  from  fungi, 
but  after  a  time  it  contains  many  fermentative  fungi, 
of  which  the  micrococcus  urese  and  bacterium  ureae  are 
most  active  in  transforming   urea  into  carbonate  of  am- 


6S 


A  CLINICAL  Manual. 


monia.  Specific  pathogenic  fungi  have  also  been 
detected  in  the  urine  in  erysipelas,  relapsing  fever, 
typhoid,  and  tuberculosis  {vide  Part  VI.). 

62>.  Chemical  Examination. — A  determination  of 
the  principal  constituents  of  the  urine  can  be  quickly 
made  by  reactions  carried  out  in  a  test-tube,  or  with 
a  small  amount  in  a  watch-glass,  water  being  added  if 
necessary. 


Fill  a  Test-Tube  Half-Full  of 

Appearance  of 

Confirmatory  Tests 

Applied  to   the 

Deposit. 

Reaction  of 

Turbid  Urine,  and  Heat. 

Deposit. 

Urine. 

I. — The  turbidity  disappears — 

Urates. 

Brick-red  deposit. 

Murexide  test. 

Usually  acid. 

II. — The  turbidity  remains. 

A  few  drops  of  cone,  acetic 

acid  are  added  ; 

a.  The  turbidity  disappears— 

Earthy  phosphates. 

White  deposit. 

Dissolves  without 

Neutral  or   al- 

effervescence. 

kaline. 

"     carbonates. 

White  deposit. 

Dissolves  with  ef- 
fervescence. 

Alkaline. 

Urate   of  ammonia 



Soluble  in  hydro- 

Alkaline. 

(slowly  soluble). 

chloric-acid  and 
murexide  test. 

b.  The  turbidity  remains — 

Uric  acid. 

Cayenne  pepper. 

Murexide  test. 

Acid. 

Oxalate  of  lime. 

White  deposit. 

Dissolves    in  hy- 
drochloric acid. 

Acid. 

Organized   sediment — 

- 

Mucus. 

Flocculent  deposit. 

The         sediment 

Usually     alka- 

partly or  wholly 

line. 

dissolves  on  the 

addition  of  caus- 

tic potash. 

Pus. 

White  deposit. 

A  stringy  gelati- 

Generally    al- 

nous mass  forms 

kaline. 

on  the  addition 

of  caustic  potash. 

Blood. 

Red  deposit. 

See  blood  in  urine. 

Acid    or   alka- 

Albumin. 

Various  tests. 

line. 
Acid   or   alka- 
line. 

69.  Micro-chemical  Examination. — Most  of  the 
crystals  are  recognized  by  the  microscopical  examina- 
tion  after   careful   study   of  their   shapes.     The  micro- 


THE  URINE.  69 

chemical  examination  is  however  of  value  in  doubtful 
cases.  Place  a  drop  of  the  reagent  at  the  edge  of  the 
cover  glass  and  observe  the  changes  resulting  from  its 
gradual  penetration  beneath  the  cover  glass.  iV  piece  of 
filtering  paper  placed  at  the  opposite  side  of  the  cover 
glass  hastens  the  action. 

1.  A  drop  of  strong  acetic  acid  dissolves  : 

a.  Of  the  crystalline 

constituents Triple  phosphates. 

Ammonium  urates  (slow- 
ly with  precipitation  of 
uric  acid  afterwards). 

b.  Of  the  amorphous 

constituents Earthy  phosphates, 

carbonates     (with 
effervescence). 
Urates     (with     precipita- 
tion of  uric  acid  after- 
wards). 

2.  A  drop  of  hydrochloric  acid  to  a  new  preparation 
of  the  same  specimen  dissolves  in  addition  to  the  above 
— calcium  oxalate. 

3.  Not  dissolved  by  acetic    Uric   acid,  the  majority 
acid  and  hydrochloric        of      the       uncommon 
acid.  sediment  and  the    or- 
ganized sediment. 

VI. — Urinary  Calculi. 

70.  Division  according  to  their  chemical  formation  : 
I.  Cystin    stones — smooth,    faintly    yellow,    not   very 
hard  ;  seldom  occur. 


70  A    CLINICAL    MANUAL. 

2.  Oxalate  stones — composed  of  calcium   oxalate  ;  the 

smaller  are  smooth  and  light  brown 
(hemp-seed  stone)  ;  the  larger  are 
rough  and  jagged,  very  hard  and 
often  dark  brown  from  the  coloring 
matter  of  the  blood  (the  mulberry- 
stone).  They  constitute  about  3 
per  cent,  of  all  the  stones, 

3.  Urate  stones — consist  of  uric  acid  alone  or  com- 

bined with  urates.  Hard,  generally 
smooth,  and  of  a  yellow  to  reddish- 
brown  color.  Stones  which  are 
composed  only  of  ammonium  urate 
(in  children)  are  small,  soft,  and  of  a 
light  yellow  color.  They  comprise 
about  three  fifths  of  all  the  calculi. 

4.  Phosphatic  stones — composed  of  earthy  phosphates 

and  triple  phosphates.  They  are 
rough  like  sand,  grayish-white,  and 
separate  easily  in  layers.  Pure  phos- 
phatic stones  are  very  rare. 

5.  Mixed  stones. — They  consist  of  strata  of  different 

formation,  generally  of  a  nucleus  of 
uric    acid  or  calcium  oxalate   (pri- 
mary   stone    formation)    and    a  pe- 
ripheral  layer  of  earthy  and  triple 
phosphates    (the    secondary    stone 
formation).     They  form  about  two 
fifths  of  all  the  stones. 
71.  Examination  of  Calculi. — The  calculus  is  trit- 
urated to  a  powder.     Large  stones  are  divided  by  sawing, 
and    separate  examinations  made    of  the  nuclear   and 
the  cortical  substance. 


THE  URINE.  yi 

1.  Heat  some  of  the  powder  on  a  platinum  foil  to  red 
heat. 

a.  It  ignites  and  leaves     Uric  acid. 

a   slight  or  no  sedi-     Cystin  (burns  with  a  blue- 
ment.  green    flame  and    has    a 

sharp  prussic  acid  odor). 
Ammonium  urates. 
Other  urates   (leave  be- 
hind a  sediment). 

b.  It  does  not  ignite  or     Calcium    oxalate    (sedi- 
only       incompletely         ment  effervesces  when 
(becomes black),  and         treated  with  an  acid), 
leaves  a  considerable     Earthly  phosphates, 
sediment      insoluble     Triple 

in  water. 

2.  Another  part  of  the  powder  is  gently  heated  with 
diluted  hydrochloric  acid  for  some  time  and  allowed  to 
cool,  to  precipitate  any  of  the  dissolved  uric  acid. 

a.  Remains        undis-     Uric    acid  (try  murexide 
solved.  test). 

b.  Dissolved Cystin. 

Calcium   carbonate   (with 

effervescence  of  gas). 
Calcium  oxalate. 
Earthly  phosphates. 
Triple 
Traces  of  uric  acid. 

To  distinguish  the  above  substances,  the  solution 
should  be  diluted,  super-saturated  with  ammonia,  then 
slightly  acidulated  with  acetic  acid. 

Remain  dissolved Earthy  phosphates. 

Triple 


72  A    CLINICAL  MANUAL. 

Distinguish  after  standing 
some  time Calcium    oxalate     (amor- 
phous or  crystalline  in- 
soluble in  ammonia). 

Cystin  (six-sided  plates 
soluble  in  ammonia). 

Iron  phosphates  (flaky 
precipitate,  generally 
only  present  when  hy- 
drochloric acid  contain- 
ing iron  is  used). 


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Part  II.— STOMACH  CONTENTS. 

I.  After  the  ingestion  of  a  meal  containing  albuminoids  and  carbo- 
hydrates (fats  are  not  affected  by  the  gastric  digestion),  amyloid  di- 
gestion occurs,  due  to  the  ptyalin  of  the  saliva,  and  the  starches  are 
gradually  converted  into  dextrine  and  grape  sugar.  This  period  lasts 
on  the  average  three  quarters  of  an  hour,  varying,  however,  with  the 
size  of  the  meal.  The  fermentation  of  the  grape  sugar  with  the  for- 
mation of  lactic  acid  due  to  micro-organisms  also  ensues. 

The  gastric  mucous  membrane  begins  to  secrete  hydrochloric  acid 
and  pepsin,  which  is  active  only  in  an  acid  medium,  as  soon  as  food 
enters  the  stomach.  The  hydrochloric  acid  is  at  first  combined,  but 
after  one  half  to  three  quarters  of  an  hour  free  hydrochloric  acid  is 
present  in  appreciable  quantity.  The  diastatic  power  of  the  saliva 
and  the  fermentative  action  of  the  micro-organisms  cannot  proceed 
in  an  acid  medium.  The  lactic  acid  disappears  in  an  hour,  and  after 
this  time  is  not  present  or  only  traces  of  it  are  found.  The  quantity  of 
free  hydrochloric  acid  continues  to  increase  and  reaches  its  maximum, 
.15  to  .25  per  cent.,  two  to  three  hours  after  the  ingestion  of  a  meal. 

2.  Examination  of  the  Stomach. — For  a  complete 
examination  of  the  stomach  it  is  necessary  to  determine  : 

a  The  Muscular  Power  of  the  Stomach. 
b  The  Absorbent  Power  of  the  Stomach. 
c  The  Power  of  Secretion  and  Digestion. 

3.  To  estimate  the  muscular  power  of  the  stomach  the 
Leube  test-meal  of  10  ounces  of  soup,  5  ounces  of  beef- 
steak, 1 1  ounces  of  bread,  and  5  ounces  of  water  may  be 
given.  After  6  to  7  hours  the  stomach  should  be  washed 
out.  If  the  stomach  is  normal,  none  or  only  traces  of 
the  food  should  be  found.  This  test  is  also  used  to  de- 
termine the  power  of  absorption  of  the  stomach. 

75 


"](>  A    CLINICAL    MANUAL, 

Riegel  employs  this  test-meal  to  estimate  the  gastric 
power  of  secretion  and  digestion.  In  such  cases  he 
washes  out  the  stomach  at  the  height  of  digestion  four 
to  five  hours  after  the  ingestion  of  the  meal.  The  Ewald 
test-breakfast,  however,  on  account  of  its  simplicity  and 
unvarying  character,  is  much  more  commonly  employed 
for  this  purpose.  It  consists  of  9  drachms  of  bread  and 
10  ounces  of  warm  water  or  very  weak  tea.  The  stomach 
contents  should  be  removed  in  an  hour  and  examined. 

4.  The  removal  of  the  stomach  contents  is  probably 
best  accomplished  by  "  Ewald's  method  of  expression.'* 
This  consists  of  pressure  upon  the  abdomen  and  active 
expression  by  the  patient,  and  usually  suffices  to  push  the 
contents  of  the  stomach  into  the  tube.  A  long  soft  rub- 
ber tube  of  large  calibre  having  several  openings  is 
usually  employed.  The  fenestras  at  the  end  of  the  tube 
and  in  the  side  close  to  the  end  should  be  smoothly 
rounded  so  as  not  to  irritate  the  mucous  membrane. 
The  tube  is  dipped  in  warm  water  and  gently  passed  into 
the  mouth  as  far  back  as  possible  and  held  there  for  a 
second  or  two.  Then  when  the  patient  begins  to  swallow 
it  can  be  rapidly  and  easily  passed  with  gentle  pressure 
into  the  stomach.  If  the  stomach  is  well  filled,  the 
contents  will  rise  in  the  tube  immediately  upon  its  intro- 
duction. If  the  stomach  is  only  partially  filled,  moderate 
pressure  over  the  abdomen  is  usually  sufficient  to  bring 
up  the  gastric  contents  through  the  tube.  If  this  proce- 
dure is  not  successful,  the  stomach  should  be  washed 
out  with  a  small  but  known  quantity  of  lukewarm  water. 
To  accomplish  this,  fill  the  tube  and  funnel,  held  up 
high,  with  water,  and  before  the  funnel  is  entirely  empty 
reverse  it  into  a  receptacle  on  the  floor  and  by  syphonic 
action  obtain  the  gastric  contents.     If  sufficient  power  is 


STOMACH  CONTENTS. 


77 


FIG.  22. — EINHORN's  STOMACH  BUCKET. 


not  secured,  it  can  be  increased  by  inverting  the  funnel 
in  a  vessel  containing  water,  pushing  the  tube  farther 
into  the  stomach,  and  raising  the  funnel  in  the  water. 

Einhorn  has  devised  an  ingenious  method  for  obtaining  a  small 
quantity  of  the  stomach  contents.     He  employs  a  small  silver  recep- 
tacle  called  a   stomach 
bucket  (Fig.  22),  which 
is    swallowed    by     the 
patient    an    hour    after 
taking  the  Ewald  test- 
breakfast.     The  bucket 
is  attached  to  a  cord  by 
which  it  is  drawn  up  after 
having  been  sufficiently 
long    in     the   stomach. 
The  author  thus  describes  the  procedure.     The  patient  is  asked  to 
open  his  mouth  widely  and  the  little  vessel  is  placed  on  the  root  of 
the  tongue  (almost  in  the  pharynx)  ;  the  patient  is  now  to  swallow 
once.     The  vessel  comes  after  a  short  time  (one  half  to  one  and  one 
half  minutes)  into  the  stomach.     This  point  can  be  easily  determined 
by  the  length  of  the  thread  from  the  vessel  to  the  mouth  as  a  knot  is 
made  on  the  cord  marking  40  ctm.,  the  usual  distance  from  the  teeth 
to  the  cardia.     When  this  knot  is  within  the  mouth,  the  vessel  is  cer- 
tainly in  the  stomach.     It  is  then  left  for  about  five  minutes  in  the 
stomach  and  thereupon  withdrawn.     During  the  withdrawal  of  the 
vessel  a  resistance  is  usually  felt  at  the  introitus  oesophagi.     This  re- 
sistance is  overcome  if  the  patient  either  deeply  expires  or  swallows 
once  when  the  vessel  reaches  this  constriction.     By  the  act  of  swal- 
lowing the  larynx  is  pushed  forward  and  upward  and  thus  the  passage 
becomes  free.     The  quantity  of  gastric  contents  thus  obtained  is  gen- 
erally sufficient  to  determine  the  presence  of  free  hydrochloric  acid. 
This  method  is  especially  recommended  in  nervous  patients  and  in 
cases  of  suspected  gastric  ulcer. 

5.  The  absorbent  power  of  the  gastric  mucous  mem- 
brane is  determined  by  the  iodide  of  potassium  test  of 
Penzoldt.     Iodide  of  potassium  is  prescribed  in  gelatine 


78  A    CLINICAL    MANUAL. 

capsules  and  the  saliva  is  tested  every  five  minutes  for  a 
trace  of  the  drug.  This  test  is  easily  made  with  filtering 
paper  saturated  with  a  starch  solution.  The  prepared 
paper  is  moistened  with  saliva  and  touched  with  fuming 
nitric  acid.  Normally  the  first  reaction,  blue  coloration 
of  the  filtering  paper,  appears  in  6  to  ii|-  minutes  if  the 
stomach  is  empty,  or  in  20  to  45  minutes  if  the  stomach  is 
full.  Iodide  of  potassium  in  keratin-coated  pills  may  be 
used  to  estimate  the  muscular  power  of  the  stomach.  The 
coating  is  not  soluble  in  the  gastric  juice  and  therefore 
the  iodide  of  potassium  is  not  absorbed  until  it  reaches 
the  small  intestine.  It  has  been  found,  however,  that 
these  pills  are  sometimes  dissolved  in  the  stomach. 

Ewald  advises  the  administration  of  salol  to  determine  the  muscular 
sufficiency  of  the  stomach.  This  is  a  phenol-salicylate  which  is  not 
affected  by  acid  fluids  but  is  split  up  by  the  pancreatic  secretion  into 
salicylic  acid  and  phenol.  Therefore,  if  phenol  and  salicyluric  acid 
appear  in  the  urine,  the  salol  must  have  passed  from  the  stomach 
into  the  intestine  and  there  been  absorbed. 

Under  normal  conditions  salicyluric  acid  appears  in  the  urine  40— 
75  minutes  after  the  ingestion  of  15  grains  of  salol,  which  is  best 
given  in  capsules  during  digestion.  This  method  has  been  found  in- 
exact, as  the  intestinal  contents  must  be  alkaline  to  act  upon  salol,  and 
this  is  influenced  by  the  intensity  of  the  reaction  and  the  quantity  of 
chyme  as  well  as  by  the  quantity  of  bile  and  pancreatic  secretion. 

Huber  has,  however,  found  that  salicyluric  acid  after  the  ingestion 
of  salol  continues  in  the  urine  for  24  hours  in  healthy  persons,  while 
in  patients  with  weakened  gastric  muscular  power  it  may  continue  for 
48  hours  or  even  longer. 

It  is  recommended  to  examine  the  urine  30  hours  after  the  adminis- 
tration of  salol.  If  the  result  is  positive  an  affection  of  the  muscular 
power  of  the  stomach  is  in  all  probability  present.  If  the  result  is 
negative  the  total  urine  excreted  between  the  30th  and  40th  hours 
must  be  examined. 

6.  To   estimate   the   gastric  power  of   secretion  and 


STOMACH  CONTENTS.  79 

digestion  it  is  necessary  to  subject  the  gastric  juice  to 
chemical  examination,  in  order  to  determine  the  state  of 
the  normal  constituents  and  the  presence  of  abnormal 
elements. 

I.  Determination  of  Hydrochloric  Acid. — Litmus 
paper  is  not  suitable  for  this  purpose,  as  it  indicates  the 
presence  also  of  facid  salts  and  organic  acids. 

A  number  of  dyes,  however,  do  not  react  with  acid 
salts,  and  are  affected  by  organic  acids  only  when  these 
acids  are  in  much  greater  concentration  than  the 
mineral  acids. 

The  organic  acids  (lactic,  acetic,  butyric  acids)  react  only  when 
there  is  more  than  .5  per  cent,  of  the  acid  present.  This  never 
occurs  in  the  gastric  contents,  as  the  fermentation  which  produces 
these  acids  is  stopped  when  .5  per  cent,  of  these  acids  is  present. 
Hydrochloric  acid,  however,  reacts  when  present  in  a  few  hundreds 
of  I  per  cent.,  providing  that  it  is  in  a  free  state  and  not  combined 
even  with  such  weak  organic  bases  as  albumin  or  peptone. 

The  following  reagents,  of  which  phloroglucin-vanilla 
is  the  best,  determine  the  presence  only  of  the  free  acids. 
Small  quantities  of  organic  acids  may  be  overlooked,  as 
their  importance,  compared  with  that  of  the  hydrochloric 
acid,  is  small.  Larger  quantities  should  be  first  re- 
moved by  repeated  shaking  with  ether  (5-7  ounces). 

a  Methyl- Aniline- Violet  Test. — The  violet  color  of  an  aqueous 
solution  of  methyl-aniline  is  changed  to  a  blue  if  .03  per  cent,  hydro- 
chloric acid  is  present,  to  a  green  if  there  is  .5  per  cent,  present,  and 
decolorized  by  i  per  cent.  Organic  acids  affect  the  color  of  this  solu- 
tion only  when  present  in  large  quantities,  i.e.,  if  .5  per  cent,  of  lac- 
tic acid  or  2.5  per  cent,  of  acetic  acid  is  present. 

Procedure. — Add  to  5-10  c.c.  (1^-2!   drachms)  of 


8o  A    CLINICAL   MANUAL. 

water  2-3  drops  of  a  concentrated  aqueous  solution  of 
methyl-violet.  The  water  assumes  a  distinctly  violet 
color.  Mix  equal  quantities  of  the  methyl-violet  solu- 
tion and  the  filtered  contents  of  the  stomach.  If  the 
mixture  becomes  decidedly  blue,  the  presence  of  more 
than  .03  per  cent,  of  hydrochloric  acid  is  proven.  The 
change  in  color  is  easily  recognized  by  a  comparison  of 
the  two  solutions. 

b  Congo-Paper  Test. — Congo-red  is  changed  to  blue  by  free  acids 
but  not  by  acid  salts.  .05  per  cent,  of  hydrochloric  acid  changes 
congo-red  to  a  dark-blue,  smaller  quantities  produce  a  faintly  blue  or 
violet  color. 

Organic  acids,  in  quantities  less  than  .5  per  cent,  have  no  effect,  or 
(lactic  acid)  produce  only  a  violet  color,  which  can  be  removed  by 
washing  ;  if  in  greater  concentration,  which  never  occurs  in  the 
stomach,  they  produce  a  dark-blue.  This  test  is  made  easily  with 
paper  which  has  been  colored  with  congo-red  after  the  manner  of 
reagent  paper. 

Procedure. — Allow  a  drop  of  the  gastric  secretion  to 
fall  on  the  congo  paper.  It  is  colored  an  intensely  dark- 
blue  {i.e.,  a  dark-blue  spot  appears)  if  hydrochloric  acid, 
at  least  .05  per  cent.,  is  present.  If  there  is  only  a 
faintly  blue  spot,  or  if  only  the  border  of  the  spot  is 
dark-blue  (a  blue  ring),  a  free  acid  is  present.  Whether 
the  acid  present  is  hydrochloric  acid  or  an  organic  acid 
or  a  mixture  of  both  cannot  be  determined  by  this  test. 

c  Tropccolin-Paper  Test. — A  yellow  to  reddish-yellow  aqueous 
solution  of  tropseolin  (00)  is  changed  on  the  addition  of  .02  per  cent, 
of  hydrochloric  acid  to  a  rose-  or  brownish-red.  Organic  acids,  in 
less  quantity  than  .5  per  cent.,  exhibit  a  yellow  coloration.  The 
test  is  readily  made  with  strips  of  paper  placed  a  short  time  before 
use  in  an  alcoholic  solution  of  this  dye  and  then  dried.  Prolonged 
saturation  weakens  their  sensitiveness.  A  good  preparation  of  the 
dye  should  be  used. 


STOMACH  CONTENTS.  8 1 

Procedure. — If  the  spot  affected  is  colored  immedi- 
ately a  dark  brownish-red,  and  after  drying  in  a  watch- 
glass  over  a  small  flame  a  lilac  color,  the  presence  of  at 
least  .05  per  cent,  hydrochloric  acid  is  shown.  Organic 
acids,  only  when  highly  concentrated,  produce  a  faintly 
brown  coloration,  but  not  the  lilac  coloration  when 
heated. 

d  Phloro-Gliicin  Vanilla  {Gimzburg's)  Test. — A  few 
drops  of  the  reagent,  consisting  of  2  parts  of  phloro- 
glucin  and  i  part  of  vanilla  in  30  parts  (by  weight)  of 
alcohol,  and  an  equal  quantity  of  filtered  gastric  secre- 
tion are  carefully  evaporated  in  a  porcelain  dish  over  a 
flame  ;  .01  per  cent,  of  hydrochloric  acid  produces  a 
beautiful  red  tinge.  Organic  acids,  even  when  present 
in  large  quantity,  do  not  give  a  reaction. 

On  heating  any  albuminous  solution  strongly,  a  deep-red,  central 
coloration  appears  after  evaporation.  This  should  not  be  confounded 
with  the  hydrochloric-acid  reaction,  which  has  the  appearance  of  red 
streaks  or  a  corresponding  red  blush  at  the  edges  on  gently  heating  or 
slowly  evaporating  to  dryness. 

This  reaction  permits  an  approximate  quantitative  estimate  of  the 
amount  of  free  acid.  By  successive  dilutions  of  the  contents  of  the 
stomach  giving  Gunzburg's  reaction  to  ^,  ^,  j^^,  etc.,  until  there- 
action  is  no  longer  perceptible,  the  quantity  of  free  hydrochloric  acid 
can  be  approximately  estimated  as  the  limit  of  the  reaction  is  about 
.05  per  mille.  If  the  red  coloration  is  still  obtained  with  the  one 
twentieth  solution,  the  gastric  juice  contains  i.o  per  mille  or  o.i  per 
cent,  of  free  hydrochloric  acid.  A  rough  guess  at  the  quantity  of  the 
acid  can  be  made  by  the  intensity  of  the  color. 

e  Resorcin  Test. — Boas  recommends  a  solution  of 
resorcin  5,  white  sugar  3,  and  diluted  alcohol  to  100. 
Three  to  five  drops  of  this  solution  are  added  to  five  or 
six  drops  of  the  contents  of  the  stomach,  and  treated  in 
the  same  way  as  in  the  preceding  test.     If  0.05  per  mille 


S2  A    CLINICAL    MANUAL. 

of  free  hydrochloric  acid  is  present,  a  rose  coloration 
appears.  This  is  never  produced  by  organic  acids, 
however  concentrated. 

2.  Lactic  Acid. — a  Iron  Chloride  Test. — One  drop  of  liquor  ferri 
sesquichloridi  gives  to  50  c.c.  (if  ounces)  of  water  a  faintly  yellow 
tinge.  If  equal  parts  of  this  solution  and  one  containing  .01  per 
cent,  lactic  acid  are  mixed,  the  mixture  has  a  decidedly  yellow  color. 
Acetic  acid,  butyric  acid,  and  acid  salts,  in  concentration  up  to  .3 
percent.,  do  not  change  the  color.  Albuminous  bodies,  salts,  pep- 
tones, and  the  like,  have  but  little  effect  upon  this  reaction.  This 
test  is  valuable  for  the  detection  of  lactic  acid  in  the  gastric  contents. 

b  Iron-Chloride  and  Carbolic- Acid  Test. — A  solution  consisting  of 
one  drop  of  liquor  ferri  sesquichloridi,  2j^  drachms  of  a  4-per-cent. 
solution  of  carbolic  acid  (or  4  drops  of  acid,  carbolic,  liq.),  and  5 
drachms  of  water  has  an  amethyst  blue  color  when  freshly  prepared. 

If  equal  parts  of  this  solution  and  of  filtered  gastric  secretion  con- 
taining .01  per  cent,  lactic  acid  are  mixed,  the  mixture  assumes  a 
yellow  or  greenish-yellow  color.  The  other  acids  which  are  present 
in  the  gastric  secretion  (hydrochloric,  acetic,  butyric  acids)  produce 
only  a  light  yellow  or  a  grayish-yellow  color  even  if  .3  per  cent,  is 
present.  The  carbolic  acid  reaction  (blue  color)  must  disappear  before 
the  characteristic  reaction  (yellow  color)  of  the  lactic  acid  can  be 
observed. 

3.  Acetic  and  Butyric  Acids. — A  not  too  small  quantity  of  the 
filtered  gastric  juice  is  shaken  with  a  large  quantity  of  ether.  If  organic 
acids  are  present,  a  fluid  residue  having  an  acid  reaction  remains 
after  evaporation.  This  has  a  characteristic  odor,  if  volatile  butyric 
acid  is  present.     Its  presence  can  be  determined  by  special  reactions. 

a  Acetic  Acid. — Dissolve  a  portion  of  the  residue  in  water, 
neutralize  exactly,  and  add  a  drop  of  iron  perchloride.  If  acetic 
acid  is  present,  it  becomes  blood-red,  and  on  boiling  a  brownish-red 
precipitate  of  basic  ferric  acetate  appears. 

Formic  acid  produces  the  same  color.  But  the  diagnostic  import- 
ance of  this  reaction  is  not  thereby  affected,  for  if  this  acid  is  found 
in  the  stomach  contents — which  up  to  this  time  has  not  been  the  case 
— its  presence,  like  that  of  acetic  and  butyric  acid,  can  be  due  only  to 
an  acid  fermentation  in  the  stomach. 


STOMACH  CONTENTS.  83 

b  Butyric  Acid. — Dissolve  the  remainder  of  the  residue  in  one 
or  two  drops  of  water  and  add  a  small  piece  of  calcium  chloride. 
The  butyric  acid  separates  from  the  rest  and  swims  on  the  surface 
as  small  globules  of  oil  on  account  of  its  insolubility  in  salt  solutions. 

4.  Determination  of  the  Total  Acidity. — This  is 
practically  a  quantitative  test  of  the  hydrochloric  acid 
if  it  is  present  in  any  amount,  as  other  acids  present  can 
usually  be  disregarded.  To  5-10  c.c.  (1-25  drachms)  of 
filtered  gastric  contents  a  one  tenth  normal  solution  of 
caustic  soda  is  added  from  a  burette  until  neutralized. 
This  point  is  easily  determined  if  a  drop  of  an  alcoholic 
solution  of  phenolphthalein  has  been  previously  added, 
the  solution  remains  colorless  while  acid  or  neutral,  but 
becomes  red  when  alkaline.  Normally  4-6.5  c.c.  of 
this  alkaline  solution  is  required  for  10  c.c.  of  gastric 
contents  (each  c.c.  =  .00365  grm.  HCl). 

5.  Digestive  Power. — Free  hydrochloric  acid  and 
pepsin  are  necessary  for  peptonizing  albumin.  Experi- 
ence has  shown  that  an  inability  of  the  gastric  juice  to 
digest  is  due  to  a  defect  in  the  acid,  as  a  complete 
absence  of  pepsin  has  very  rarely  been  observed.  The 
digestive  test  is  therefore  only  another  test  for  hydro- 
chloric acid.  It  permits  by  the  rapidity  of  its  action  a 
more  reliable  estimate  of  its  quantity  than  the  intensity 
of  the  color  reaction  allows.  The  result  obtained  from 
the  determination  of  hydrochloric  acid  by  the  color 
reaction  and  that  deduced  from  the  test  of  the  digestive 
power  will  practically  always  agree  with  one  exception, 
/.  ^.,  where  lactic  acid,  which  is  completely  free  (not 
combined  with  albumin)  is  present.  This  acid  in  contra- 
distinction to  the  other  organic  acids  acts  with  pepsin 
almost  as  vigorously  as  hydrochloric  acid.  A  gastric 
secretion  which  contains  pepsin  and  lactic  acid,  but  no 


84  A    CLINICAL   MANUAL. 

hydrochloric    acid,    can    still    digest    very    well,    but    is 
abnormal  in  spite  of  that  fact. 

a  Carmine  Fibrin  Test. — Fibrin,  which  has  been  obtained  in 
flakes  by  whipping  blood,  is  washed  with  water  until  colorless,  and 
then  placed  in  an  ammoniacal  solution  of  carmine  for  twenty-four 
hours.  After  removal  from  this  solution  the  fibrin  is  repeatedly 
washed  with  water  until  it  ceases  to  color  the  water.  The  flakes, 
still  a  dark  red,  are  placed  in  glycerine  where  they  can  be  preserved 
unchanged  for  years.  They  should  be  thoroughly  washed  with  water 
before  their  use.  The  coloring  material  has  so  completely  permeated 
the  fibrin  that  it  cannot  be  removed  by  any  solvent,  not  even  by 
diluted  hydrochloric  acid.  It  is  only  after  the  fibrin  has  been 
digested  that  the  solution  containing  it  becomes  colored,  and  the 
digestive  power  of  the  fluid  thus  becomes  apparent.  The  carmine 
fibrin  is  a  very  delicate  reagent  for  the  determination  of  the  digestive 
power. 

Procedure. — Wash  thoroughly  with  water  some  of 
the  flakes  of  carmine  fibrin,  and  place  them  in  a  .2  per 
cent,  solution  of  hydrochloric  acid.  Remove  the  excess 
of  acid  by  pressing  with  the  fingers,  and  place  the  fibrin 
in  a  test-tube.  Put  a  like  quantity  of  fibrin,  thoroughly 
washed  with  water  but  not  treated  with  hydrochloric 
acid,  in  another  test-tube.  Pour  into  both  of  the  test- 
tubes  5-10  c.c.  (1J-2J  drachms)  of  the  filtered  gastric 
contents.  If  the  gastric  secretion  contains  hydrochloric 
acid  and  pepsin  in  sufficient  quantity,  the  fibrin  will  be 
partially  dissolved,  giving  a  red  coloration  to  the  fluid 
within  five  minutes  at  the  temperature  of  the  room.  If 
the  digestion  is  active,  all  the  fibrin  is  quickly  dissolved. 
If  the  red  coloration  appears  only  in  the  test-tube  con- 
taining the  fibrin  treated  with  hydrochloric  acid,  the 
gastric  juice  is  deficient  in  hydrochloric  acid ;  if  the 
reaction  also  fails  in  this  test-tube,  the  gastric  juice  is 
deficient  both  in  pepsin  and  hydrochloric  acid. 


STOMACH  CONTENTS.  85 

b.  Egg-Albumin  Test. — The  albumin  of  boiled  eggs  is  divided  into 
small  disks  |  of  an  inch  in  diameter  and  -^^  of  an  inch  thick.  These 
can  be  preserved  in  glycerine  in  the  same  manner  as  the  fibrin.  They 
are  much  less  soluble  than  the  fibrin  flakes  in  the  gastric  juice,  and 
require  for  their  solution,  if  the  gastric  juice  is  active,  \-\  hour  at 
100°  F.  An  exact  differentiation  in  the  digestive  power  can  therefore 
easily  be  made  by  this  test. 

Procedure. — Wash  thoroughly  the  disks  of  albumin 
with  water,  and  place  two  of  them  in  each  of  two  test- 
tubes,  add  10  c.c.  (2I-  drachms)  of  filtered  gastric  secre- 
tion to  both.  1-2  drops  of  concentrated  (25  per  cent.) 
hydrochloric  acid  are  added  to  the  contents  of  one  of 
the  test-tubes.  They  are  then  placed  in  a  thermostat 
heated  to  100°  F.  If  pepsin  is  present  in  sufficient  quan- 
tity, the  disks  should  be  dissolved,  after  1-2  hours,  at 
least  in  the  test-tube  to  which  the  hydrochloric  acid  has 
been  added. 

6.  Rennet  Ferment. — Add  a  few  drops  of  the  filtered 
gastric  juice  to  some  fresh  milk  (3-4  drachms)  ;  if  the 
rennet  ferment  is  present,  curdling  will  occur  in  a  few 
minutes. 

7.  Bile. — (a)  Bile  pigment  is  detected  by  Gmelin's  test.  If  the 
reaction  of  the  gastric  contents  is  acid  the  larger  part  remains  insolu- 
ble in  the  sediment.  It  should  therefore  first  be  dissolved  by  the 
addition  of  diluted  alkalies,  and  then  the  test  be  applied.  The  bile 
pigment  does  not  usually  appear  in  the  form  of  bilirubin  but'  in  that 
of  biliverdin,  as  is  evident  by  the  green  color.  The  color  reaction 
accordingly  begins  with  a  blue  ring.  The  bile  pigment  can  be  ex- 
tracted from  the  solid  gastric  contents  by  warm  alcohol  with  the  addi- 
tion of  some  drops  of  diluted  sulphuric  acid.  The  extract  is  a 
beautiful  green  to  bluish-green  solution  of  biliverdin. 

(b)  Biliary  acids  are  detected  by  Pettenkofer's  reaction.  Evapo- 
rate some  of  the  fluid  in  a  small  porcelain  dish,  after  the  addition  of 
1-3  drops  of  diluted  sulphuric  acid  (16  per  cent.)  and  of  a  very  small 
quantity  of  cane-sugar,  with  continuous  shaking  over  a  small  flame  at 


86  A    CLINICAL   MANUAL. 

a  temperature  of  6o°-8o°  C.  (140°-!  76°  F.).  If  biliary  acids  are 
present,  in  amount  over  .05  per  cent.,  a  beautiful  purplish-red  color 
appears  immediately  or  during  the  evaporation  at  about  the  point  of 
dryness.  Overheating  must  be  avoided  by  continuous  shaking,  also 
the  addition  of  too  much  sugar,  as  in  either  case  a  black  product  may 
result,  which  disguises  this  reaction. 

Albuminous  bodies,  peptone,  and  many  other  organic  compounds 
give  a  similar  color.  If  they  are  present,  the  Pettenkofer's  test  is 
not  reliable,  and  the  biliary  acids  must  first  be  isolated. 

8.  HAEMOGLOBIN  (Blood). — Unaltered  haemoglobin  is  found  in 
the  gastric  contents  only  in  vomitus  following  quickly  large  hemor- 
rhages. It  is  changed  in  most  cases  to  a  product  resembling  coffee- 
grounds,  the  color  of  which  is  due  to  the  formation  of  haematin. 

(i)  Determination  by  the  test  for  heemin. 

A  drop  of  the  sediment  is  dried  on  a  slide  by  gentle  heat,  the 
further  procedure  is  the  same  as  16,  4. 

(2)  Determination  by  Heller's  Test  {vide  page  21). 

Make  an  extract  of  the  sediment  with  diluted  caustic  soda.  If 
hsematin  is  present,  the  extract  has  a  brown  color.  Filter,  add  an 
equal  volume  of  normal  urine  (in  order  to  supply  earthy  phosphates), 
and  boil.  If  hsematin  is  present,  the  phosphates  are  precipitated  in 
beautiful  red  crystals. 

9.  Ammonium  Carbonate. — This  is  present  in  the  stomach  in 
cases  of  uraemia  and  cholera  as  a  result  of  the  metamorphosis  of  urea. 
The  addition  of  caustic  soda  to  the  stomach  contents  volatilizes  the 
ammonia,  which  is  recognized  by  its  penetrating  odor  and  by  the 
formation  of  a  haze  on  a  glass  rod  moistened  with  acetic  or  hydro- 
chloric acid.  This  haze  is  due  to  the  union  and  condensation  of  the 
gaseous  ammonia  and  the  vapor  either  of  the  acetic  or  hydrochloric 
acid  forming  either  the  acetate  or  the  chlorate  of  ammonium. 

Traces  of  ammonia  may  be  detected  in  the  following  manner  :  a 
piece  of  red  litmus  paper  is  stuck  on  the  convex  side  of  a  watch-glass. 
This  is  placed  on  a  wide  test-tube  which  contains  some  of  the  gastric 
contents,  to  which  a  few  drops  of  caustic  soda  have  been  added.  The 
ammonia  is  evolved  on  the  addition  of  the  caustic  soda,  and  changes 
the  color  of  the  test  paper. 

It  should  always  be  remembered  that  no  matter  how- 
complete  our  chemical  apparatus  or  how  scientific  our 


STOMACH  CO \' TENTS.  8/ 

procedure,  we  cannot  duplicate  in  test-tubes  the  condi- 
tions existing  in  the  human  organism.  The  results  ob- 
tained in  artificial  digestion  must  always  be  imperfect, 
and  our  deductions  should  therefore  be  correspondingly 
conservative. 

7.  Vierordt  gives  the  following  as  of  diagnostic  value  : 

1.  When  examination  shows  that  the  duration  of  diges- 
tion is  not  lengthened,  digestion  is  generally  normal.  It 
may,  however,  be  shortened,  and  this  condition  occurs  at 
times  with  hyperacidity. 

2.  When  free  hydrochloric  acid  is  absent  at  the  nor- 
mally highest  point  of  digestion,  it  may  be  due  to  : 

(a)  Complete  destruction  of  the  gastric  mucous  mem- 
brane, as  in  atrophy  and  in  amyloid  degeneration  of  the 
stomach  (constant). 

(b)  Carcinoma  of  the  stomach  with  dilatation  (almost 
constant),  other  forms  of  dilatation  (very  often),  and  of 
these  especially  chronic  catarrh. 

3.  Diminished  acidity  (even  absence)  has  been  ob- 
served in  : 

(a)  Severe  forms  of  anaemia 

(b)  Fever 

(c)  Certain  cases  of  nervous  dyspepsia. 

4.  Hyperacidity  has  been  noticed  in  : 

(a)  Most  of  the  cases  of  gastric  ulcer 

(b)  Certain  forms  of  nervous  dyspepsia 

(c)  Acute  and  at  times  chronic  gastric  catarrh. 
Thanks  to  the  new  method  of  examination  by  means 

of  the  stomach-tube,  the  knowledge  of  diseases  of  the 
stomach  has  been  greatly  advanced  and  the  dif- 
ferentiation of  their  pathological  conditions  made 
much  more  reliable.  It  is  nevertheless  natural  that 
much  is  still  the  subject  of  controversy  in  a  field  which 


88  A    CLINICAL    MANUAL. 

has  been  investigated  in  a  scientific  manner  only  in  the 
last  decade.  There  is  also  the  danger  that  symptoms 
found  in  individual  cases  will  be  considered  diagnostic  of 
the  disease.  Thus  it  is  with  the  alleged  increased  acid 
secretion  in  ulcer  of  the  stomach  and  absence  of  hydro- 
chloric acid  in  cancer  of  the  stomach.  We  should  there- 
fore keep  in  mind  that  this  or  that  hypothesis,  which  to- 
day is  considered  true  or  very  probable,  may  in  course 
of  time  prove  to  be  erroneous  or  require  to  be  essentially 
modified — "  Leube's  Specielle  Diagnose." 


Part  III.— FiECES. 

The  physical  properties  and  the  microscopic  examina- 
tion of  the  faeces  give  valuable  diagnostic  indications, 
but  the  chemical  examination  on  account  of  its  com- 
plexity is  of  less  value. 

I  Bile-Pigment. — The  bile-pigments,  unaltered,  are 
not  normally  present  in  the  faeces  but  appear  in  the  form 
of  hydrobilirubin  (urobilin),  which  is  not  detected  by 
Gmelin's  test.  They  are,  however,  present  in  catarrhal 
conditions  of  the  small  intestine  and  produce  the  green 
color  of  the  faeces.  As  they  are  soluble  in  alkalies  and 
insoluble  in  acids,  they  are  either  in  the  fluid  or  in  the 
solid  part  according  to  the  reaction,  and  may  be  detected 
by  Gmelin's  reaction. 

2.  Albumin. — Dilute  the  faeces  with  a  very  weak  solu- 
tion of  acetic  acid,  filter  repeatedly,  and  examine  the  fil- 
trate for  albumin. 

3.  Blood. — Blood,  coming  from  the  stomach  or  upper 
part  of  the  intestines,  is  in  the  form  of  methaemoglobin 
and  haematin,  and  gives  a  brownish-red  to  brownish-black 
color  to  the  faeces.  Pure  blood  occurs  only  after  profuse 
hemorrhages  arising  close  to  the  anus. 

Its  presence  is  determined  as  in  Part  II.,  8. 

(a)  By  the  haemin  test. 

(b)  By  Heller's  test. 

4.  Crystals. — i.  Triple  Phosphate.  —  Occur  nor- 
mally and  in   different  pathological  conditions. 

89 


90  A    CLINICAL  MANUAL. 

For  microscopical  appearance  and  chemical  character 
see  Part  I,  49, 

2, — Phosphate  of  Lime. — Similar  to  the  above  {vide 
Part  I,  46). 

These  and  other  lime  salts  are  often  colored  intensely- 
yellow  by  the  bile-pigment. 

3.  Oxalate  of  Lime. — (Envelope  shape)  due  to 
vegetable  food  {vide  Part  I,  45). 

4.  Lactate  of  Lime — Present  in  enteritis,  especially 
in  that  of  children  in  the  shape  of  sheaves  of  fine 
needles. 

5.  Organic  Salts  of  Lime  and  Magnesia. — Needles 
grouped  together  in  tufts  and  balls,  present  in  large  num- 
bers in  acholia  (pernicious  jaundice). 

6.  Cholesterin. — Crystals,  soluble  in  ether.  Recog- 
nised easily  by  means  of  sulphuric  acid  and  iodine  {vide 
infra,  5,  I). 

7.  HiEMATOiDiN — Yellowish-red  crystals  ;  present  after 
intestinal  hemorrhage. 

8.  Charcot-Leyden  Crystals. — The  union  of  a  phos- 
phate with  an  organic  base  of  the  formula  CgHgH. 
Colorless,  faintly  brilliant,  of  pyramidal  shape  often  with 
convex  surface  (resembling  the  small  waxy  bodies  often 
found  in  prostatic  secretion).  Insoluble  in  cold  water, 
alcohol,  ether,  or  chloroform.  Very  soluble  in  acids,  alka- 
lies, and  in  alkaline  carbonates. 

They  occur  in  pathological  conditions  ;  anaemia,  caused  by  anchy- 
lostoma  duodenalis,  dysentery,  typhoid  fever,  etc.  They  have  also 
been  found  in  the  expectoration  especially  in  bronchial  asthma  ;  in 
the  blood,  the  spleen,  and  marrow  in  leukaemia  ;  in  the  excretion  of 
the  prostate  gland. 

A  mixture  of  one  drop  of  this  and  one  drop  of  a  i-per-cent.  solution 
of  ammonium  phosphate  shows,  when  examined  under  the  microscope, 


PMCES.  91 

beautifully  shaped  crystals  immediately  or  after  an  hour.     Their  de- 
tection is  of  value  in  differentiating  prostatarrhoea  from  gonorrhoea. 

5.  Concretions. — Dilute  the  faeces  with  water  to  the 
consistency  of  a  thin  pulp  and  strain  through  muslin  to 
find  stones. 

1.  Gall-Stones. — They  consist  principally  of  calcium 
carbonate  combined  in  varying  quantities  with  choles- 
terin  and  bilirubin  ;  the  nucleus  contains  a  larger  propor- 
tion of  lime  combined  with  bilirubin.  They  are  of  a 
whitish-yellow,  seldom  of  a  brownish-red  color,  greasy 
to  the  touch,  with  glistening  lines  of  fracture,  and  weigh 
proportionately  much  less  than  other  stones.  If  a  portion 
is  heated  on  a  platinum  foil,  it  melts  and  ignites  with  a 
flame  leaving  an  ash. 

For  a  complete  chemical  analysis,  they  are  broken  up 
and  boiled  in  water  to  dissolve  traces  of  biliary  acids  and 
other  matter.  The  sediment  is  treated  with  a  mixture 
of  equal  volumes  of  ether  and  alcohol.  The  cholesterin 
is  dissolved,  the  biliary  coloring  matter  (principally 
bilirubin)   combined  with  calcium  remains  undissolved. 

The  cholesterin  is  crystallized  usually  in  large,  thin, 
rhomboidal  plates,  less  often  into  glistening  needles 
when  the  solution  is  diluted.  Place  some  of  the  choles- 
terin on  a  slide,  and  add  concentrated  (80  <fo)  sulphuric 
acid,  the  edges  of  the  plates  dissolve,  and  the  plates 
become  carmine  red,  which  is  changed  to  violet  on  the 
addition  of  Lugol's  solution. 

The  bilirubin-calcium  is  dissolved  in  diluted  hydro- 
chloric acid,  and  the  bilirubin  removed  by  chloroform. 
It  can  then  be  crystallized  or  subjected  to  Gmelin's  test. 

2.  Intestinal  Stones.  They  consist  usually  of  an 
organic  nucleus  (fruit  stone,  blood  coagulum,  hardened 


92  A    CLINICAL   MANUAL, 

faecal  mass)  and  peripheral  layers  of  earthy  and  triple 
phosphates.  To  determine  its  composition,  the  stone 
should  be  divided.  One  portion  should  be  subjected  on 
a  platinum  foil  to  heat,  and  another  part  to  diluted 
hydrochloric  acid  at  a  gentle  heat.  The  phosphates  are 
dissolved,  the  cholesterin  and  nuclear  substance  are 
insoluble,  and  must  be  subjected  to  a  microscopical 
examination. 


Part  IV.— THE   BLOOD. 

1.  The  blood  is  an  alkaline  fluid,  whose  specific 
gravity  ranges  from  1035-1068,  and  which  constitutes 
about  one  thirteenth  of  the  body-weight.  Its  color  is 
either  bright  red  (arterial  blood)  or  dark  red  (venous 
blood),  depending  upon  the  state  of  the  haemoglobin. 
The  haemoglobin  is  contained  in  the  red  blood-cells,  and 
forms  a  loose  combination  with  the  oxygen  of  the  air  called 
oxy-h^moglobin,  which  is  bright  red.  As  the  blood  cir- 
culates, the  haemoglobin  gives  up  almost  all  its  oxygen  to 
the  tissues,  and  as  a  result  the  blood  becomes  dark  red. 

Changes  in  the  quantity  or  quality  of  the  blood  are  of  the  greatest 
clinical  importance,  as  such  changes  affect  the  functions  of  the  blood  ; 
the  carrying  of  oxygen  from  the  air  to  the  tissues,  the  conveying  of 
nutrient  material  from  the  alimentary  tract  to  the  rest  of  the  body, 
and  the  transporting  of  the  products  of  combustion  to  the  principal 
excretory  organs, — the  lungs  and  the  kidneys. 

The  elements  of  the  blood. — The  blood  consists 
of  a  nearly  colorless  liquid,  the  plasma,  red  and  white 
cells  (leucocytes),  and  the  so-called  blood-plates  ;  of 
these,  the  blood-plasma  and  blood-plates  are  as  yet  of 
no  clinical  importance. 

2.  Red  Blood-Cells. — They  are  bi-concave  disks 
with  rounded  edge,  and  of  an  average  diameter  of  7-8 
fA..  They  usually  arrange  themselves  on  a  slide  in  rows 
like  rolls  of  coin,  and  singly  look  like  circular  plates  if 
flat,  and  biscuit-shaped  if  on  edge.     When  brought  within 

93 


94 


A    CLINICAL   MANUAL. 


focus,  they  have  a  light  centre  and  dark  periphery.  The 
individual  cells  are  pale  yellow,  of  homogeneous  struc- 
ture, and  without  nuclei.  The  red  blood-cells  at  the  pe- 
riphery of  a  preparation  become  shrunken  and  crenated 
due  to  evaporation,  while,  upon  the  addition  of  water, 
they  swell  and  lose  their  central  concavity.  There  are 
normally  in  the  male  about  5,000,000,  and  in  the  female 
4,500,000  red  blood-cells  in  a  cubic  millimetre  of  blood. 

Pathological  Changes  in  the  Red  Blood-Cells. — The  number  maybe 
increased  (policythaemia)  or  diminished  (oligocythsemia),  the  size 
and  form  changed  (poikilocytosis),  so  that  they  appear 
pear-,  flask-,  anvil-,  hammer-,  and  star-shaped.  Some 
may  be  unusually  large  (10-14  yW),  megalocytes  ;  and 
others  exceedingly  small,  microcytes.  Some  of  the 
red  blood-cells  may  have  nuclei,  and  are  called  normo- 
blasts if  of  normal  size,  ^nd  megalo-  or  gigantoblasts 
if  3-5  times  larger  than  normal  cells.  The  normo- 
blasts are  found  normally  in  bone  marrow  of  adults, 
the  megaloblasts  in  that  of  the  embryo.  The  quantity 
of  haemoglobin,  which  the  red  blood-cells  contain,  may 
vary  in  different  morbid  states. 

An  increased  number  of  red  cells  in  a  cubic  milli- 
metre of  blood  occurs  in  conditions  of  hunger,  and 
in  states  marked  by  a  depletion  of  the  system  of 
watery  elements,  as  in  cholera  and  dysentery.  A 
diminution  in  number  may  be  due  to  a  direct  loss  of 
blood  as  after  hemorrhage,  to  a  decreased  formation 
W  or  increased  destruction  of  red  cells  as  in  conditions 

„,  of   mal-nutrition,     in    infectious    diseases,    toxicoses, 

FIG.  23. —  .  ,         ' 

THOMA-ZEISS    neoplasms,  etc.     A  change  in  the  shape  and  size  of 

H.-EMACYTG-    red  blood-cells,  and  the  appearance  of  nucleated  red 

METER  CAPIL-  cells  characterize  certain  pathological  conditions. 

When  any  or  all  of  these  changes  in  red  blood-cells 

are  marked,  an  ordinary  microscopic  preparation  made  with  care  will 

show  that  the  red  blood-cells  are  less  numerous,  their  color  paler, 

their   shape    unusual,    or    their    normal    proportion    to    the    white 

blood-cells   (550  red  blood-cells    to   one    white    cell)    altered.     If 


"■^ 


THE   BLOOD, 


95 


the  changes  are  slight,  or  if  exact  results  are  desired,  special 
apparatus  must  be  used  to  determine  the  degree  of  oligocythsemia  or 
oligochromsemia  (decrease  in  haemoglobin).  Of  the  various  instru- 
ments devised,  the  Thoma-Zeiss  apparatus  for  counting  blood-cells, 
and  the  V.  Fleischl's,  and  the  Gowers'  instruments  for  determining 
the  percentage  of  haemoglobin  give  the  most  satisfactory  results. 

3.  The  Thoma-Zeiss  Hemacytometer,  an  apparatus  for 
counting  blood-cells,  consists  of  a  glass  capillary  tube  about  10 
cm.  long  (Fig.  23),  which  at  b  expands  to  a  bulb,  containing  a 
freely  movable  small  glass  ball.  The  tube  is  graduated,  and  has 
figures  0.5  and  i  beneath,  and  loi  above  the  bulb.  A  counting 
space  in  a  receptacle  cemented  upon  a  slide  completes  the  appa- 
ratus. The  floor  of  this  space  is  divided  into  squares  ;  the  depth  of 
each  is  exactly  -^-^  mm. ,  the  sides  -^^  mm. ,  and  the  volume  of  each 
tiny  cube  ^oo'  cubic  millimetre  (Fig.  24). 

Procedure. — Blood,  obtained  by  puncturing  the  thor- 
oughly   clean    finger,    is^  >.._.  .j...^  ^ 

drawn  up  either  to  the 
mark  0.5  or  i,  then  the 
diluting  solution  (3^  Na 
CI)  to  the  mark  10 1,  and 
the  tube  well  shaken. 
The  blood  in  the  capil- 
lary tube  is  blown  out 
and  then  the  counting 
space  filled  with  the  di- 
luted blood  and  a  cover 
glass  carefully  pushed 
over  it  from  the  side  so 
that  no  air  bubbles  are  included.  The  preparation  is 
allowed  to  stand  for  one  or  two  minutes  to  permit  the 
red  blood-cells  to  settle  and  then  placed  under  the  micro- 
scope. The  field  is  seen  to  be  divided  into  a  number  of 
small  squares,  arranged  in  larger  squares  of  16,  marked  off 
by  double  lines.     All  the  blood  cells  within  a  large  square 


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FIG.  24. — THOMA-ZEISS   HEMACYTO- 
METER.      SLIDE   FOR   COUNTING. 


96 


A    CLINICAL   MANUAL. 


of  1 6  small  squares  are  counted,  together  with  those 
impinging  upon  the  upper  and  left  borders  while  those 
touching  the  lower  and  right  are  disregarded.  The 
greater  the  number  of  large  squares  examined,  the 
more  accurate  is  the  result.  The  common  practice  is 
to  count  the  number  of  cells  in  lo  large  squares  (i6o 
small  squares).  The  number  of  red  blood-cells  in  a 
cubic  millimetre  of  blood  is  the  result  obtained  by 
multiplying  the  number  of  red  blood-cells  counted,  by 
4000  and  by  the  degree  of  dilution  (100  or  200)  and 
dividing  the  product  by  the  number  of  squares  taken. 

N  X  4000  X  100 

X  = 

160 
X  =  Number  of  red  blood-cells  in  a  cubic  millimetre  of 
blood. 

N  =:  Number  of  red  blood-cells  in  160  squares. 

The  white  blood-cells  can  be 
counted  in  the  same  manner  and 
with  the  same  instrument  as  the 
red  cells,  but  the  liability  to 
error  is  very  much  greater  as  the 
white  blood-cells  are  so  few  in 
number.  Several  preparations 
should  therefore  be  made  and 
counted.  A  capillary  tube 
which  allows  a  dilution  of  ten- 
fold has  been  constructed  for 
counting  the  white  blood-cells. 
A  solution  of  acetic  acid  .3  to 
.5  per  cent,  to  which  a  sinall 
quantity  of  an  aniline  dye  has 
been  added  is  employed.  This 
solution  dissolves  the  red 
blood-cells  and  stains  the  white 


FIG.  25. — GOWERS'  HAEMOGLO- 
BINOMETER. 


cells.     3-5  preparations  should  be  examined  to  obtain  results  of  value. 


THE   BLOOD.  97 

4.  GowERS'  H.-EMOGLOBINOMETER. — It  consists  of  two  glass  tubes 
(Fig.  25,  A.  and  B.)  of  exactly  the  same  size,  c>ne  of  which  contains 
a  carmine-picro-carmine  gelatine  which  has  exactly  the  same  tint  as  a 
i-per-cent.  aqueous  solution  of  normal  blood.  The  other  tube  is 
graduated  from  10-120  and  receives  the  blood  to  be  examined  and 
the  diluting  solution  (distilled  water).  There  are  in  addition  a 
capillary  tube  (C),  a  bottle  of  distilled  water  with  dropper  (D),  and 
a  needle  (E). 

Procedure. — The  finger  is  thoroughly  cleaned  and 
pricked  with  the  needle  and  20  cubic  millimetres  of 
blood  are  drawn  into  the  capillary  tube.  This  is  then 
blown  into  tube  B  which  should  contain  a  few  drops  of 
water.  After  shaking  the  tube  for  a  minute,  dilute  it 
with  distilled  water,  drop  by  drop,  from  the  stopper  of 
bottle  D,  until  the  tint  of  the  diluted  blood  is  the  same 
as  that  of  the  carmine  gelatine.  If  the  tints  are  similar 
when  the  tube  is  filled  to  the  mark  100,  the  quantity  of 
haemoglobin  is  normal  ;  if  it  requires  greater  dilution, 
the  haemoglobin  is  in  excess,  if  less  dilution,  it  is  below 
normal  in  quantity  as  indicated  by  the  figures  of  the 
scale.  The  tubes  should  be  held  before  a  sheet  of  white 
paper  when  compared  and  the  determination  should  be 
made  by  daylight.  The  results  are  only  approximate  but 
sufficiently  exact  for  clinical  purposes. 

5.  Von  Fleischl's  H^mometer. — This  apparatus  consists  of  a 
small  stand  like  that  of  a  microscope  with  a  stage  which  has  a  circu- 
lar opening  in  the  centre,  beneath  which  is  a  plate  of  plaster-of-Paris, 
resembling  a  mirror,  to  reflect  light.  Under  the  stage  is  placed  a 
movable  wedge  of  red  (Cassius'  golden  purple)  glass  in  a  metallic 
frame  which  has  a  graduated  scale.  The  circular  opening  in  the 
stage  is  for  a  small  metallic  cylinder  with  glass  bottom,  which  is 
divided  by  a  vertical  partition  into  two  equal  divisions,  one  of  which 
receives  light  which  has  passed  through  the  red  glass  wedge,  while  the 
other  receives  light  directly  from  the  plaster-of-Paris  reflector.  An 
automatic  capillary  tube  and  a  dropper  complete  the  apparatus 
(Fig.  26). 

7 


98 


A    CLINICAL    MANUAL. 


Procedure. — The  finger  is  punctured  and  the  capil- 
lary tube  filled  with  blood.  The  tube,  after  all  the  blood 
on  the  outside  is  carefully  wiped  off,  is  placed  horizon- 
tally in  one  of  the  divisions  of  the  cylinder,  which  should 
contain  a  little  distilled  water,  and  is  shaken  about  to 
wash  out  the  blood.  When  most  of  the  blood  is  removed, 
hold  the  tube  vertically  over  the  same  division  and  wash 
it  within  and  without  with  distilled  water  from  a  dropper, 
thus  removing  all  the  blood.     Then  place  the  cylinder  in 


FIG.  26. — VON  FLEISCHL's  H^MOMETER. 


the  circular  opening  and  fill  both  divisions  to  the  brim 
with  distilled  water.  The  wedge  of  red  glass  is  then 
moved  until  the  tints  as  they  appear  through  the  divi- 
sions of  the  cylinder  seem  similar.  The  percentage  of 
haemoglobin  is  indicated  by  the  scale.  The  determina- 
tion should  be  made  by  yellow  light  (gas  or  oil). 

Care  should  be  taken  to  always  thoroughly  wash  the 
capillary  tubes  with  distilled  water,  alcohol,  and  ether 
after  use. 


THE  BLOOD.  99 

6.  The  White  Blood-Cells  (Leucocytes). — They 
are  masses  of  protoplasm  having  nuclei  and  possessing 
amoeboid  movements.  They  vary  greatly  in  size  but  aver- 
age about  10  }i  in  diameter,  appear  singly  in  the  micro- 
scopical field  and  are  recognized  by  their  granular  surface. 
The  nuclei  are  at  times  seen  in  fresh  preparations  and 
can  always  be  made  visible  by  the  addition  of  diluted 
acetic  acid.  Their  size  and  the  shape  and  size  of  the 
nuclei  divide  them  into  four  groups. 

A.  S^nall  Lyi7iphocytes. — Small  mononuclear  cells  about 
the  size  of  a  red  blood-cell  with  a  relatively  large  round 
nucleus,  which  is  deeply  stained  by  aniline  dyes. 

B.  Large  Lymphocytes. — Mononuclear  cells,  about  twice 
the  size  of  the  small  lymphocytes,  with  a  relatively  small 
oval  nucleus.  Both  this  and  the  preceding  group  are 
formed  in  the  lymph  glands,  the  small  being  regarded  as 
an  earlier  stage  of  the  large  lymphocytes. 

C.  Leucocytes  with  irregular  or  multiple  nuclei. — They 
are  somewhat  larger  than  the  red  blood-cells  and  have 
strongly  refracting,  finely  granular  protoplasm.  They 
have  either  a  single  irregular  nucleus  or  several  nuclei 
due  to  division.  This  group  constitutes  the  great  major- 
ity of  the  white  blood-cells. 

D.  Leucocytes  with  coarsely  granular  protoplasm. — A 
small  number  of  group  c  are  characterized  by  highly 
refracting,  coarsely  granular  protoplasm.  They  are  called 
coarsely  granular  leucocytes  or  eosinophilic  cells. 

7.  The  number  of  leucocytes  in  a  cubic  millimetre  of 
blood  ranges  normally  from  6000  to  10,000,  /.  .?.,  one  to 
800-500  red  blood-cells.  An  increase  in  their  number, 
called  leucocytosis,  occurs  at  times  in  health  (physiologi-^ 
cal  leucocytosis)  and  in  certain  morbid  conditions  {patho- 
logical leucocytosis). 


lOO  A    CLINICAL    MANUAL.  i 

Physiological  Icucocytosis  is  usually  present  several  hours  after  the 
ingestion  of  food,  in  the  latter  part  of  pregnancy,  and  in  the  new- 
born. 

Pathological  leucocytosis  may  be  either  an  accompaniment  of 
diseased  processes  or  the  principal  symptom  of  a  definite  disease 
(leukaemia). 

It  is  present  in  chronic  cachectic  conditions  and  after  repeated 
hemorrhages. 

It  may  occur  in  certain  inflammatory  diseases  and  is  then  called 
inflammatory  leucocytosis.  A  marked  leucocytosis  (15-20,000)  is 
said  to  characterize  inflammations  of  serous  membranes  of  a  suppura- 
tive character,  a  less  pronounced  leucocytosis  those  of  a  sero-fibrinous 
character,  while  such  inflammations  when  tubercular  show  no  in- 
crease in  the  number  of  leucocytes.  The  most  marked  inflammatory 
leucocytosis  is  found  in  croupous  pneumonia.  The  increase  appears 
a  few  hours  after  the  chill  and  quickly  reaches  20,000-30,000 
leucocytes  in  a  cubic  millimetre  of  blood.  The  number  decreases 
markedly  in  24  hours  but  remains  until  the  crisis  above  normal.' 
Non-exudative  inflammatory  processes  without  great  inanition,  as 
malaria,  measles,  and  scarlet  fever,  if  uncomplicated,  show  no  in- 
crease of  leucocytes,  while  those  characterized  by  pronounced  in- 
anition, as  typhoid  fever,  exhibit  a  marked  diminution  in  leucocytes. 
Leucocytosis  in  typhoid  fever  indicates  a  complication  of  a  suppura- 
tive character.  A  more  or  less  pronounced  leucocytosis  has  been 
observed  in  sepsis,  puerperal  fever,  erysipelas,  diphtheria,  and  re- 
current fever. 

A  very  pronounced  leucocytosis  (35,000-320,000)  and  a  change  in 
the  character  of  the  leucocytes  are  the  pathognomonic  symptoms  of 

'  It  would  seem  as  if  the  degree  of  leucocytosis  furnishes  us  an  in- 
dication of  the  effort  which  the  system  is  able  to  make  in  order  to 
overcome  the  infection.  When  the  degree  of  leucocytosis  in  pneu- 
monia is  markedly  low  (under  10,000),  the  system  reveals  its  inability 
to  react,  and  the  prognosis  is  therefore  almost  always  fatal.  When 
the  degree  of  leucocytosis  is  high,  it  indicates  an  infection  of  great 
severity,  but  shows  the  vigorous  reaction  of  the  system  against  the 
poison,  rendering  the  prognosis  favorable  unless  some  complication 
ensues. 


THE  BLOOD.  lOI 

leuTcsemia,  The  change  in  the  leucocytes  was  first  shown  by  Ehrlich, 
who  discovered  that  the  protoplasm  of  the  white  cells  contain,  coarse 
and  fine  granules  which  react  differently  with  aniline  dyes,  and  that 
similar  cells  are  characterized  by  the  same  kind  of  granules.  He 
therefore  classified  the  leucocytes  according  to  this  differential  action 
with  aniline  stains.  Three  of  these  types,  which  are  called  after 
letters  of  the  Greek  alphabet,  alpha,  beta,  gamma,  etc.,  are  of  im- 
portance in  the  investigation  of  the  human  blood,  and  are  differenti- 
ated from  one  another  by  the  fact  that  they  are  each  stained  by  a 
pigment  of  a  different  reaction  and  by  that  alone.  They  are,  there- 
fore also  called  eosinophile  (acid),  basophile  (basic),  or  neutrophile 
(neutral).  The  knowledge  of  the  increase  or  appearance  of  these 
cells  is  said  to  be  of  great  clinical  value. 

1.  The  Alpha  or  Eosinophilic  Granules. — The  protoplasm  of 
these  cells  is  characterized  by  coarse  granules  which  are  stained  only 
by  acid  aniline  dyes,  of  which  eosin  is  one.  They  generally  have  one, 
at  times  two,  and  rarely  three  nuclei.  They  are  said  to  have  their 
origin  in  the  marrow  and  number  2-8  per  cent,  of  the  leucocytes  in 
normal  blood,  but  are  increased  in  number  in  leukaemia. 

2.  The  Gamma,  Mast  Cell,  or  Basophilic  Granules. — Fine 
granules  stained  only  by  basic  aniline  dyes  as  dahlia,  gentian-violet, 
etc.  They  were  said  to  occur  only  in  pathological  conditions  (leu- 
kaemia) in  small  numbers,  but  they  have  also  been  found,  though 
rarely,  in  healthy  blood. 

3.  The  Epsilon  or  Neutrophilic  Granules. — They  are  char- 
acterized by  very  fine  granules,  one  or  more  very  irregular  nuclei 
having  the  shape  of  the  letters  S,  V,  F,  M,  etc.,  and  are  stained  by 
neutral  aniline  dyes,  i.  e.,  a  mixture  of  acid  and  basic  aniline  dyes,  as 
methyl-blue  and  acid  fuchsin.  About  70  per  cent,  of  the  leucocytes 
in  normal  blood  belong  to  this  group. 

8.  Examination  of  Blood. — The  pulp  of  the  finger 
or  the  lobe  of  the  ear  should  be  thoroughly  cleaned 
with  alcohol  and  then  punctured  with  a  needle.  Cover- 
glasses,  which  have  been  kept  in  alcohol,  are  carefully 
dried,  touched  to  the  blood,  which  should  not  be  pressed 
out,  then  inverted  on  clean  slides  when  preparations  of 


102  A    CLINICAL  MANUAL. 

fresh  blood  are  desired,  or  immediately  covered  with 
other  glasses  and  at  once  slid  apart  if  permanent  prepa- 
rations are  wanted.  Another  method  consists  in  passing 
the  edge  of  one  end  of  a  slide  through  the  blood,  then  in 
dravvdng  the  slide,  held  at  an  angle  of  45°,  quickly  across 
a  cover  glass,  steadied  with  a  finger  of  the  other  hand, 
thus  spreading  a  thin  film  of  blood  over  the  glass.  The 
film  of  blood  dries  very  quickly  and  may  be  "  fixed  " 
for  staining  either  by  being  placed  for  1-2  hours  in  a 
mixture  of  equal  parts  of  alcohol  and  ether,  or  being 
subjected  to  a  temperature  of  120°  to  130°  C.  (248°  to 
266°  F.).  This  degree  of  heat  is  easily  obtained  by  ar- 
ranging a  copper  plate  (12x4  inches)  beneath  one  end  of 
which  an  alcohol  lamp  is  lit.  In  about  half  an  hour  the 
heat  of  the  plate  becomes  constant,  /.  e.^  radiation  is  equal 
to  conduction,  and  the  boiling  point  on  the  plate  is 
where  drops  of  water  are  immediately  converted  into 
steam,  beginning,  of  course,  at  the  end  farthest  from  the 
flame.  A  point  an  inch  nearer  the  flame  than  the  boil- 
ing point  will  have  the  desired  temperature  (about  120° 
C).  The  glasses  are  placed,  besmeared  side  uppermost, 
on  this  spot  and  left  there  for  an  hour.  They  are 
now  ready  for  staining,  and  after  staining  are  rinsed  in 
water,  dried  with  filtering  paper,  and  mounted  in  Canada 
balsam. 

9.  Staining  Solutions. 

.1-.5  per  cent,  aqueous  solution  of  eosin. 

The  cover-glasses  should  be  floated  with  besmeared  side  downward 
for  10-20  minutes  in  this  solution,  then  washed  in  water,  dried,  and 
mounted.  If  the  solution  is  heated,  the  time  required  for  staining  is 
shortened. 

.  2-.  5  per  cent,  alcoholic  solution  of  eosin. 

Stains  in  \-\  miniite. 

The  red  blood-cells  are  stained  a  uniform  red,  the  protoplasm  of 


THE  BLOOD.  I03 

the    leucocytes  is  faintly  stained,  and   the    eosinophilic  granules    a 
strikingly  deep  red. 

Rieder  recommends  a  method  for  double  staining  which  gives  very 
satisfactory  results.  He  places  a  drop  or  two  of  a  saturated  solution 
of  eosin  in  carbol-glycerine  (carbolic  acid  5  per  cent.)  upon  a  pre- 
pared cover-glass  and  covers  it  with  another  besmeared  glass.  After 
24  hours  the  glasses  are  separated,  washed  thoroughly  with  water  and 
stained  for  10-15  minutes  in  haematoxylon  (Delafield's)  diluted  with 
an  equal  volume  of  water.  They  are  then  washed,  dried,  and  mounted 
in  Canada  balsam.  The  red  blood-cells  are  stained  a  uniform  eosin 
red,  the  eosinophilic  granules  a  strikingly  bright  red,  and  the  nuclei 
of  the  leucocytes  a  dark  purple  (Fig.  27,  See  end  of  volume.) 

The  following  formulae  are  recommended  by  Ehrlich  and  other 
workers  in  this  field. 

Czenzynski's  solution  : 

Methylene  blue,  concentrated  aqueous  solution 40 

\  per  cent,  solution  of  eosin  in  70  per  cent,  alcohol    20 
Distilled  water 40 

This  solution  gently  heated  stains  in  fifteen  minutes.  The  red  blood- 
cells  appear  eosin-red,  the  eosinophilic  granules  bright  red,  and  the 
nuclei  dark  blue.  A  good  result  is  obtained  by  staining  for  2-3  min- 
utes in  a  heated  .5  per  cent,  alcoholic  solution  of  eosin,  and  then  the 
same  length  of  time  in  a  saturated  aqueous  solution  of  methylene  blue, 

Eosin  ) 

Aurantia  >•  of  each 2 

Nigrosin  (or  indulin)    ) 

Glycerine 30 

This  solution  acts  in  16-24  hours.  The  red  blood-cells  are  stained 
orange,  the  protoplasm  of  the  leucocytes  a  dirty  gray,  the  nuclei  much 
darker,  and  the  eosinophilic  granules  a  bright  red. 

Ehrlich's  hsematoxylin-eosin  solution  : 

Hsematoxylin 4.-5. 

Glacial  acetic  acid 20. 

Distilled  water    ] 

Alcohol  \  of  each , 100. 

Glycerine  ) 

Alum  in  excess. 


104  ^    CLINICAL    MANUAL. 

This  solution  is  exposed  to  the  light  for  three  weeks  and  i  per  cent. 
eosin  added.  The  preparations  should  be  stained  for  24  hours.  The 
red  blood-cells  appear  a  strawberry  red,  their  nuclei,  if  present,  a  deep 
black,  the  protoplasm  of  the  leucocytes  a  light  lilac  and  their  nuclei 
a  deep  lilac.  The  eosinophilic  granules  are  a  brilliant  reddish  purple, 
the  nuclei  of  the  lymphocytes  look  dark  and  their  protoplasm  is 
faintly  stained. 

Ehrlich's  tri-acid  solution  : 

Distilled  water lOO 

Orange  G 135 

Acid  fuchsin 65 

Distilled  water 100 

Absolute  alcohol 100 

Methyl  green 125 

Distilled  water 100 

Absolute  alcohol 100 

Glycerine 100 

They  are  gradually  mixed  together  and  the  solution  is  allowed  to 
stand  for  a  time.  The  cover-glasses  are  kept  for  five  minutes  in  this 
solution.  The  red  blood-cells  are  stained  yellow  and  their  nuclei, 
when  present,  greenish-blue.  The  neutrophilic  leucocytes  show  fine 
violet-colored  granules  and  greenish-blue  nuclei.  The  eosinophilic 
granules  are  stained  a  brilliant  red. 

Ehrlich's  neutral  solution  : 

Saturated  aqueous  solution  of  acid  fuchsin 5. 

Concentrated  aqueous  solution  of  methylene  blue. . . .  i. 
Distilled  water 5. 

Add  gradually  with  continuous  shaking  to  the  fuchsin,  the  solution 
of  methylene  blue,  then  the  water,  and  filter.  After  standing  a  few 
days  the  solution  stains  in  5-20  minutes. 

Saturated  alcoholic  solution  of  dahlia 50. 

Glacial  acetic  acid 10. 

Distilled  water , 100 

Especially  recommended  for  the  gamma,  basophilic  granules. 

The  author  doubts  the  practical  clinical  value  of  this  work  for  the 
physician,  though  it  may  be  of  use  in  the  laboratory  to  demonstrate 


THE  BLOOD. 


105 


th(5  progressive  development  of  leucocytes  or  in  special  researches  in 
certain  diseases  of  the  blood.  The  claim  that  by  this  method  the 
different  forms  of  leukaemia  can  be  diagnosticated  earlier  would 
hardly  compensate  for  the  labor  involved  in  such  work  when  it  is 
considered  how  rare  a  disease  leukaemia  is,  occurring  only  once  in 
sixty  thousand  cases  in  Wurzburg,  and  once  in  a  thousand  cases  in 
Vienna.  Ehrlich's  work,  however,  has  drawn  attention  to  the  study  of 
the  leucocytes  and  their  increase  in  number  in  various  morbid  con- 
ditions. Such  investigations  seem  to  point  to  a  field  rich  in  diagnostic 
and  prognostic  results. 

lo.  The  following  is  a  short  summary  of  the  usual 
condition  of  the  blood  found  in  the  various  forms  of 
anemia,  necessarily  only  approximate  and  in  exceptional 
cases  inexact. 

Chlorosis. — The  blood  is  microscopically  evidently 
paler,  and  the  quantity  of  haemoglobin  reduced  to  50, 
40  per  cent,  and  less.  The  number  of  red  blood-cells  is 
usually  normal  or  slightly  diminished,  and  their  shape  is 
generally  unchanged.  The  leucocytes  are  not  increased 
in  number,  but  at  times  they  may  be  relatively  increased. 
In  severe  cases  the  haemoglobin  is  reduced  to  about  20 
per  cent  (even  to  10  per  cent.),  the  number  of  red  blood- 
cells  is  markedly  diminished  (2-3,000,000)  and  they 
exhibit  marked  poikilocytosis. 

Anaemia. — This  is  usually  a  secondary  disease,  and 
the  changes  in  the  blood  depend  upon  the  character  and 
duration  of  the  primary  disease  (phthisis,  carcinoma, 
syphiHs,  chronic  nephritis,  etc.).  There  is  a  more  or 
less  marked  diminution  in  the  number  of  red  blood-cells 
and  a  proportionate  decrease  in  haemoglobin.  The 
number  of  leucocytes  is  usually  normal,  though  it  may  be 
increased.  The  shape  of  the  red  blood-cells  is  generally 
unchanged,  but   in  severe   cases  there  may  be  marked 


Io6  A    CLINICAL  MANUAL, 

poikilocytosis,  and  some  of  the  red  blood-cells  may  be 
nucleated  (Fig.  28,  See  end  of  volume.) 

Progressive  Pernicious  Anaemia. — The  red  blood- 
cells  are  always  very  much  reduced  in  number,  even  to 
less  than  1,000,000,  and  the  haemoglobin  is  also  much 
diminished,  but  not  to  such  a  degree  as  the  red  blood- 
cells.  There  is  pronounced  poikilocytosis  with  little  ten- 
dency to  the  formation  of  rolls.  Many  microcytes  and 
numerous  megalocytes  are  seen.  Large  nucleated  red 
blood-cells  are  almost  always  found  either  in  small 
number  or  quite  numerous.  The  number  of  leucocytes 
is  normal  though  there  is  a  relative  increase. 

Leukaemia. — In  advanced  cases  the  diagnosis  is  easily 
made  by  a  superficial  microscopical  examination  of  the 
blood.  In  the  early  stage  a  careful  examination  is  neces- 
sary, not  only  the  counting  of  the  red  and  white  blood- 
cells  but  also  the  staining  of  the  dried  preparations 
being  then  of  value.  The  characteristic  of  leukaemic 
blood  is  the  enormous  and  progressive  increase  of  leu- 
cocytes, even  to  360,000  from  8-9000,  so  that  the  ratio 
of  white  to  red  may  be  changed  from  i:  550  to  i:  30,  or 
even  1 :  2  when  the  number  of  red  cells  is  greatly  re- 
duced. The  red  blood-cells  are  paler  than  normal, 
variable  in  size,  and  usually  moderately  reduced  in 
number  though  exceptionally  the  reduction  may  be 
excessive.  The  diminution  in  the  haemoglobin  generally 
corresponds  to  that  of  the  red  blood-cells.  The  leu- 
cocytes show  striking  differences.  Small  and  medium- 
sized,  finely  granular  leucocytes,  and  many  highly  re- 
fractive and  coarsely  granular  cells  are  seen.  If  the  small 
mononuclear  leucocytes  (lymphocytes)  predominate,  the 
lymph  glands  are  especially  involved.  If  the  large  cells 
are  the  more  numerous,  the  marrow  and  spleen  are  the 


THE  BLOOD.  10/ 

more  affected  ;  the  spleen,  if  in  each  field  there  appear  3-5 
cells  filled  with  highly  refracting  granules  ;  the  marrow, 
if  very  large  mononuclear  leucocytes  are  seen  (Fig.  29. 
See  end  of  volume). 

Pseudo-Leukemia. — The  condition  of  the  blood  is 
similar  to  that  found  in  secondary  anaemia,  a  variable 
reduction  in  the  number  of  red  blood-cells,  a  correspond- 
ing diminution  in  the  haemoglobin,  but  none  of  the 
changes  characteristic  of  leukaemia  are  present. 


Part  v.— PATHOLOGICAL   FLUIDS. 

1.  Transudates  are  transparent  yellow  or  greenish- 
yellow  alkaline  fluids  containing  few  cellular  elements 
(leucocytes,  endothelial  cells).  They  do  not  coagulate 
spontaneously,  or  if  so  only  after  a  time.  If  they  contain 
blood  either  through  transudation  or  as  a  result  of  the 
puncture,  a  gelatinous  or  membranous  coagulation  of 
fibrin  results.  Old  transudates  into  serous  cavities  lose 
this  characteristic.  Transudates  have  a  low  specific 
gravity  and  contain  albumin  (fibrinogen,  serum  globulin, 
serum  albumin).  Both  the  specific  gravity  and  the 
quantity  of  albumin  vary,  however,  with  the  region  of 
transudation  and  increase  progressively  in  transudates 
into  the  tunica  vaginalis,  the  pleural  and  peritoneal  cavi- 
ties, the  skin,  and  the  cerebral  cavities.  The  other  solid 
constituents  are  neither  important  nor  characteristic. 

2.  Exudates. — The  serous  exudates  alone  need  be 
considered,  as  the  suppurative  and  hemorrhagic  are 
easily  recognized.  The  exudates  are  similar  in  color  to 
the  transudates,  but  contain  more  cellular  elements  and 
are  therefore  cloudy.  They,  almost  without  exception, 
coagulate  either  immediately  after  their  evacuation  or  at 
the  longest  after  twenty-four  hours. 

The  addition  of  diluted  acetic  acid  produces  a  precipitate  of  a  sub- 
stance similar  to  globulin,  which,  in  contra-distinction  to  that  formed 
in  the  transudates,  is  dissolved  with  great  difficulty  in  an  excess  of 
the  acid,  and  is  insoluble  in  a  solution  of  sodium  chloride.  The 
exudates  have  a  higher  specific  gravity,  contain  more  albumin  than 

io8 


PATHOLOGICAL   FLUIDS. 


roQ 


the  transudates,  and  do  not  vary  in  these  elements.  But  the 
differences  are  not  so  marked  that  these  two  fluids  can  always  be 
sharply  separated  from  each  other.  More  often  there  are  transitions, 
i.  e.,  transudates  which  contain  more  albumin  than  the  exudate  con- 
taining the  least  albumin,  and  the  reverse.  Reuss  has,  however, 
determined  certain  limits,  the  minimum  of  albumin  and  of  the  specific 
gravity  for  exudates,  and  the  maximum  of  the  same  for  transudates. 
They  are  : 


Percentage 

of  albumin. 

Specific 

gravity. 

Exudate 

Transudate 

Exudate 

Transudate 

more  than 

less  than 

higher  than 

lower  than 

Hydrothorax. .        4.0 

2.5 

1018 

1015 

Ascites 4.0-4.5 

1.5-2.0 

( i 

1012 

Anasarca 4.0 

1. 0-1.5 

t( 

lOIO 

Hydrocephalus. 

0.5-1.0 

<( 

1009 

The  determination  of  the  quantity  of  albumin  or  simply  of  the 
specific  gravity  '  furnishes,  when  other  symptoms  fail,  an  easy  method 
of  differentiating  a  transudate  from  an  exudate.  This  is  the  case 
only  when  no  complications  are  present. 

The  most  exact  method  of  estimating  the  albumin  is  to  coagulate 
it  and  weigh  the  coagulum.  The  approximative  methods,  given  under 
urinary  analysis,  can  also  be  used.  The  specific  gravity  is  determined 
in  the  same  manner  as  that  of  urine.  If  the  fluid  is  cloudy  it  should  be 
clarified  by  standing  or  by  filtration.  Clear  fluids  also  should  stand 
for  twelve  hours,  if  exact  results  are  desired,  as  they  have  a  lower 
specific  gravity  before  the  evaporation  of  the  gases  which  they 
contain. 

3.  Contents  of  Ovarian  Cysts. — The  contents  of  ovarian  cysts 
differ  much  in  character,  from  an  aqueous,  light-yellow,  clear  alka- 
line fluid,  to  a  tough,  stringy,  mucilaginous  body  of  whitish,  dirty- 
brown,  or  yellowish-green  color.     The  specific  gravity  ranges  from 


'  The  specific  gravity  and  the  quantity  of  albumin  usually  corre- 
spond, as  albumin  is  the  only  solid  constituent  whose  quantity  varies. 
Exceptions  occur  when  large  quantities  of  sugar  (diabetes),  of  urinary 
elements  (uraemia),  or  of  chyle  (obstruction  in  the  secretion  of  milk) 
pass  into  the  serous  cavities. 


no  A    CLINICAL    MANUAL, 

I002    to    1055,   but    is    usually  between  loio  and  1024 ;    generally 
higher  than  that  of  exudates  and  transudates. 

The  fluid  contains  albumin  (serum  globulin  and  serum  albumin)  in 
varying  quantities,  and  always  pseudomucin,  a  body  pathognomonic  of 
ovarian  fluids,  and  which  gives  them  their  peculiar  character — turbid 
and  stringy — when  present  in  large  quantity.  The  aqueous  solutions 
of  pseudomucin  are  mucilaginous,  are  filtered  with  difficulty,  and  have 
the  following  chemical  relations  : 

1.  Heated  to  the  boiling  point :  no  precipitate. 

2.  Addition  of  acetic  acid  :  no  precipitate  (differentiates  it  from 
mucin). 

3.  The  general  reactions  for  albumin  : 

Nitric  acid. 

Acetic  acid  -f-  sodium  chloride. 

Acetic  acid  -\-  ferrocyanide  of  potassium  :  no  precipitate — the 
solution  only  becomes  more  dense. 

4.  Boiling  with  Millon's  reagent :  reddish-brown  coloration. 

5.  Addition  of  alcohol :  a  fibrinous  precipitate,  soluble  in  water, 
even  after  remaining  in  alcohol  for  a  day. 

6.  Boiling  with  diluted  mineral  acids  :  formation  of  a  body  which 
can  reduce  cupric  oxide. 

If  the  ovarian  fluid  contains  a  large  quantity  of  pseudomucin,  it  has 
a  thick  gelatinous  character,  and  forms,  with  alcohol,  a  characteristic 
fibrinous  precipitate.  If  the  quantity  of  pseudomucin  is  small,  this 
characteristic  is  not  marked.  In  such  cases,  as  indeed  in  all,  the 
following  tests  should  be  made  if  a  positive  determination  is  desired  : 

Pseudomucin.  a.  Heat  Test. — Boil  the  fluid,  which 
has  been  faintly  acidulated  with  diluted  acetic  acid,  add 
carefully  a  few  drops  of  acetic  acid  until  a  flaky  precipi- 
tate of  albumin  appears,  and  proceed  exactly  as  described 
on  page  15.  If  the  filtrate  is  transparent,  no  pseudo- 
mucin is  present  ;  if  the  filtrate  is  whitish,  opalescent, 
pseudomucin  may  be  present.  Such  a  filtrate  may  be 
obtained  from  a  solution  of  pure  albumin  by  the  incom- 
plete coagulation  of  the  albumin  (compare  page  15). 
Therefore,  several  tests  should  be  made,  and  the  quantity 


PATHOLOGICAL  FLUIDS.  Ill 

of  acetic  acid  added  to  each  should  be  purposely  varied. 
If  all  the  tests  give  the  same  result — i.  e.^  a  cloudy,  opal- 
escent filtrate, — the  presence  of  pseudomucin  is  probable. 
The  following  test  is,  however,  much  more  delicate  : 

b.  Reduction  Test. — The  filtrate  is  concentrated  on  a 
water  bath,  and  precipitated  with  alcohol.  The  flaky  pre- 
cipitate is  separated  and  placed  in  water.  If  pseudomucin 
is  present,  it  is  dissolved,  making  the  fluid  opalescent.  A 
part  of  this  fluid  is  submitted  to  Trommer's  test  for  sugar 
— /.  e.^  reducing  substance.  The  result  will  be  negative,  as 
reducing  substances,  if  they  had  been  present,  would 
have  remained  in  solution  in  the  alcohol.  Add  to  the 
rest  of  the  fluid  an  excess  of  acetic  acid  ;  if  a  precipitate 
(mucin  ?)  results,  it  is  removed  by  filtration,  and  hydro- 
chloric acid  to  the  amount  of  5  per  cent,  is  added.  The 
fluid  is  heated  in  a  test-tube  until  it  becomes  a  brownish- 
yellow  or  brown.  It  is  n^ltralized  with  concentrated 
caustic  soda,  when  cool,  and  again  subjected  to  Trom- 
mer's test.  If  pseudomucin  was  originally  present,  a 
marked  precipitate  of  cupric  suboxide  (hamarsten)  re- 
sults. Nylander's  test  also  gives  a  positive  result.  If  the 
ovarian  fluid  is  typical,  10  c.c.  (2^  drachms)  are  sufficient 
to  produce  this  reduction.  If  the  fluid  has  the  character 
of  water,  several  hundred  c.c.  (4-10  ounces)  are  necessary. 

4.  Contents  of  Hydronephrosis. — The  fluid  evacuated  in 
hydronephrosis  is  usually  colorless,  transparent,  having  a  specific 
gravity  of  1008  to  1020,  and  resembles,  in  its  composition,  diluted 
urine.  Traces  of  albumin  are  often  found.  Its  character  is  frequently 
affected  by  secondary  changes  ;  if  mucus  or  pus  is  admixed,  it  is 
cloudy  and  contains  albumin  ;  if  there  is  complete  anuria,  the 
characteristic  urinary  elements  are  absent. 

A  correct  diagnosis  by  chemical  examination  is  possible  only  vi^hen 
the  characteristic  urinary  elements  (urea  and  uric  acid)  are  present  in 


112  A    CLINICAL   MANUAL. 

large  amount.  Small  amounts  have  been  found  in  other  fluids  (urea 
in  echinococcus  cysts,  uric  acid  in  ascitic  fluid  in  cases  of  arthritis). 
The  presence  of  renal  epithelium  should  be  carefully  looked  for  in 
the  sediment  of  the  liquid  which  has  been  allowed  to  settle. 

Urea. — The  fluid  is  neutralized  and  evaporated  on  a 
water  bath  until  it  has,  when  cool,  the  consistency  of 
thin  syrup.  Place  a  drop  on  a  slide,  cover  with  glass,  at 
the  edge  of  which  place  a  drop  of  nitric  acid.  If  urea 
is  present,  a  crystalline  precipitate  of  nitrate  of  urea  is 
formed,  immediately  or  after  some  time,  at  the  junction 
of  the  fluids.  The  usual  shape  is  a  rhomboidal  plate, 
which  at  times  becomes  hexagonal.  They  generally 
lie  upon  one  another  like  slates.  This  simple  method 
of  examination  is  possible  only  in  fluids  which  have 
relatively  a  large  quantity  of  urea  and  do  not  contain 
albumin  and  similar  substances.  In  such  cases,  evapo- 
rate the  fluid  to  the  consist^Pby  of  a  thick  syrup,  extract 
with  alcohol,  and  then  evaporate  the  extract  to  a  like 
consistency.  Crystals  of  urea  (long,  thin,  four-sided 
prisms)  sometimes  appear.  Dissolve  the  sediment, 
especially  the  crystallized  portion,  freed  from  alcohol  by 
pressing  in  filtering  paper,  in  water,  and  test  as  before  for 
a  precipitate  of  nitrate  of  urea.  If  no  precipitate  results, 
the  fluid  does  not  contain  the  quantity  of  urea  necessary 
for  the  positive  diagnosis  of  hydronephrosis. 

Uric  Acid. — If  the  fluid  contains  albumin,  remove 
it  (inde  page  15).  Evaporate  the  filtrate  to  a  small 
volume,  add,  when  cool,  a  few  drops  of  hydrochloric 
acid,  and  place  in  the  cold.  If  uric  acid,  in  not  too 
small  a  quantity,  is  present,  a  crystalline  precipitate  is 
formed.  This  is  recognized  as  uric  acid  by  its  form 
and  by  the  murexide  test. 

5.  Echinococcus  Cysts. — The  fluid  of  the  echino- 


PATHOLOGICAL  FLUIDS.  113 

coccus  cysts  is  usually  clear,  of  a  neutral  or  alkaline 
reaction,  of  low  specific  gravity,  1.007-1,015,  and  contains 
much  sodium  chloride,  which  is  crystallized  on  evapora- 
tion. Albumin  is  usually  absent,  or  only  traces  are  found. 
If  a  large  quantity  of  albumin  is  present,  it  is  due  to  re- 
peated punctures.  Succinic  acid  is  a  constant  constitu- 
ent, and  its  salts  are  found  in  small  amount.  These  are 
detected  by  a  simple  method.  Evaporate  the  fluid  to 
the  consistency  of  a  syrup,  acidulate  with  hydrochloric 
acid,  and  extract  with  ether.  The  succinic  acid  appears 
as  imperfect  crystals  (large  prisms  and  hexagonal  plates) 
after  diluting  the  ether.  Its  aqueous  solution  forms  a 
rusty-colored,  flaky,  or  gelatinous  precipitate  of  succinate 
of  iron  with  ferric  chloride.  The  booklets  and  portions 
of  the  echinococcus  membrane  which  are  absolutely 
diagnostic  should   be  sought  after. 

8 


Part    VI.— PATHOGENIC    MICRO-ORGAN- 
ISMS. 

I.  The  Bacillus  Tuberculosis. — The  discovery  by 
Koch  that  a  bacillus  is  the  cause  of  all  tubercular  pro- 
cesses, has  enabled  us  to  determine  whether  or  not  a 
morbid  condition  is  tubercular.  This  discovery  has  been 
of  especial  value  in  pulmonary  tuberculosis,  in  the  latent 
forms  and  in  the  early  stages  before  the  physical  signs 
are  well  marked.  //  can  be  stated  as  a  clinical  law  that 
the  p7'ese7ice  of  this  bacillus  in  the  sputu77i  always  indicates 
tuberculosis. 

Their  presence,  however,  in  the  sputum  does  not  make  the  prog- 
nosis in  all  cases  of  pulmonary  tuberculosis  unfavorable,  as  such 
cases  may  and  do  recover.  Their  apparent  absence,  on  the  other 
hand,  does  not  negative  the  diagnosis  of  pulmonary  tuberculosis,  as 
so  few  may  be  present  as  to  escape  detection  unless  repeated  and 
careful  examinations  have  been  made. 

The  tubercle  bacilli  are  short,  slender  rods  1.5  /^  to  3.5  /f  (.00006 
to  .00014  of  an  inch)  in  length,  approximately  about  one  fourth  to 
one  half  the  diameter  of  a  red  blood-cell.  They  are  either  quite 
straight  or  less  often  more  or  less  curved,  and  in  pulmonary  tuber- 
culosis they  are  usually  found  singly  or  in  groups  in  the  small  tough 
greenish-yellow  masses  which  are  expectorated.  Their  detection 
is  made  possible  by  the  fact  that  they  retain  various  aniline  dyes 
longer  than  the  other  elements  of  the  sputum  when  subjected  after 
staining  to  a  decolorizing  agent. 

Preparation  of  the  Cover-Glasses. — Spread  the 
sputum  on  a  dark  surface  (a  dark  plate  or  a  glass  on  a 
black  background),  and  seek  out  the  small  tough  green- 
ish-yellow masses.     Separate  one  of  these  with  a  needle 

114 


PATHOGENIC  MICRO-ORGANISMS.  I15 

and  smear  some  Of  it  on  an  absolutely  clean  cover-glass, 
one  which  has  been  washed  in  distilled  water,  then  in 
alcohol,  and  carefully  dried.  Cover  this  diagonally  with 
a  second  glass  (Fig.  30),  carefully  press  them  together 
between  the  fingers,  making  a  thin 
even  layer  on  each  glass,  then  slide 
them  apart.  After  the  cover-glasses 
have  been  dried  in  the  air  or  by 
gentle  heat,  /.  e.  held  between  the  fin- 
gers at  a  distance  from  a  flame,  pass 
them,  held  with  forceps,  and  with  be- 
smeared side  uppermost,  three  times    ^^*^-   3o.    arrange- 

,  in  1       ^  -^  MENT   OF  COVER- 

throusrh  a  flame,  each  transit  occupy- 

°  '  ^  ■'  GLASSES. 

ing  a  little  more  than  a  second,  to 
coagulate  and  thus  fix  the  albumin.  The  preliminary 
drying  must  have  been  complete  or  the  result  will  be  of 
less  value,  as  the  protoplasm  of  the  bacteria  when  coagu- 
lated at  a  high  temperature  loses  its  normal  outline. 
They  are  now  ready  for  staining.  When  stained  they 
are  mounted  in  Canada  balsam  on  a  slide  and  examined 
under  the  microscope.  An  oil-immersion  lens  and  an 
Abbe  condenser  should  be  used,  although  a  lower  mag- 
nifying power  is  sometimes  sufficient  to  distinguish  them. 
Staining. — Many  methods  for  staining  the  tubercle 
bacillus  have  been  recommended  and  are  in  use,  but 
that  of  Ziehl  and  Neelsen  is  probably  the  simplest  and 
gives  very  satisfactory  results. 

METHOD  OF  ZIEHL  AND  NEELSEN. 

STAINING    SOLUTION. 

Distilled  water.  100  c.c. 

Alcohol.  10.  c.c. 

Carbolic  acid  in  crystals.  5  grams. 

Fuchsin  in  substance.  i  gram. 


Il6  A    CLINICAL    MANUAL. 

The  solution  is  easily  prepared  when  required  by  mix- 
ing one  part  of  a  concentrated  alcoholic  solution  of 
fuchsin  and  nine  parts  of  a  5-per-cent.  solution  of  car- 
bolic acid.  The  cover-glass  is  floated  for  five  minutes, 
with  besmeared  side  downwards,  in  this  solution  in  a 
porcelain  dish,  the  solution  being  gently  heated  to  steam- 
ing. It  is  then  transferred  from  the  staining  solution  to  a 
20-per-cent.  solution  of  nitric  acid,  or  preferably  to  a  5- 
per-cent.  solution  of  sulphuric  acid,  for  decolorization.  It 
should  be  held  with  forceps  and  moved  gently  about  in  the 
diluted  acid  for  a  few  seconds  only,  until  the  preparation, 
which  was  a  deep  red,  loses  its  color  and  becomes  yel- 
lowish-brown. It  is  now  washed  with  a  diluted  (70  per 
cent.)  solution  of  alcohol  renewed  several  times  until 
the  alcohol  is  no  longer  discolored,  rinsed  in  water,  dried 
with  filtering  paper,  and  mounted  in  Canada  balsam. 
The  bacilli  appear  as  slender  red  rods,  while  the  other 
elements  are  unstained.  A  contrast  stain  is  easily  made 
by  placing  the  cover-glass  after  it  has  been  washed  with 
alcohol  in  a  very  diluted  (i  per  cent.)  aqueous  solution 
of  methylene  blue  for  three  minutes.  It  is  then  rinsed 
in  water,  dried,  and  mounted.  The  bacilli  remain  col- 
ored red  because  when  once  stained  they  are  affected  by 
another  stain  only  with  great  difficulty,  while  the  other 
elements,  other  bacteria,  fungi,  mucus,  corpuscles,  and 
epithelia  are  stained  blue  (Fig.  31).^ 

Gabbet  recommends  the  following  solution  of  methylene  blue  in 
sulphuric  acid  for  decolorization  and  contrast  staining  after  the  use 
of  Ziehl's  solution  : 

Sulphuric  acid  (25  per  cent.)         100  c.  c. 

Methylene  blue  1-2  grams. 

The  cover-glasses  should  remain  in  this  solution  1-2  minutes.    This 
^  For  illustration  see  end  of  volume. 


PA  THOGENIC  MICRO-ORGANISMS.  11/ 

modification,  though  it  simplifies  a  little  the  procedure,  removes  the 
control  of  the  decolorization  which  the  original  method  gives. 

The  part  of  the  staining  procedure  which  many  beginners  find 
difficult  is  the  decolorization  by  the  acid,  either  allowing  the  cover- 
glass  to  remain  in  the  acid  solution  too  long  and  thus  decolorizing 
also  the  bacilli,  or  too  short  a  time  and  thereby  not  extracting  suffi- 
ciently the  stain  from  the  other  elements.  Frequent  trials  with 
sputum  known  to  contain  bacilli  will  usually  remove  this  difficulty. 

The  bacilli  of  tuberculosis  have  also  been  found  in  the 
urine,  and  their  presence  indicates  a  tubercular  condi- 
tion of  some  part  of  the  urinary  tract.  The  attempts  at 
their  detection  in  the  urine  have  been  most  laborious  and 
usually  profitless.  Prudden  recommends,  however,  a 
procedure  which  renders  their  detection  much  more 
easy.  A  large  quantity  of  urine,  that  of  one  or  two  days, 
is  allowed  to  settle  for  twelve  hours  in  long  cylinders  of 
small  diameter.  The  portion  deposited  is  drawn  off  and 
still  further  concentrated  by  revolving  it  in  the  Litten 
centrifugal  machine  (Fig.  lo)  for  three  minutes.  A  lit- 
tle of  the  sediment  thus  obtained  is  placed  on  a  cover- 
glass,  which  is  treated  exactly  in  the  manner  described 
for  the  staining  of  the  bacilli  in  sputum. 

2.  Micrococcus  Gonorrhoea  (GoNococcus). — These 
cocci  usually  occurring  in  pairs  or  in  groups  of  four  are, 
as  a  rule,  flattened  on  the  sides  which  lie  together,  being 
thus  "  biscuit-shaped  "  (semmelformige).  Various  spe- 
cies of  micrococci  have  this  shape,  but  it  is  their  occur- 
rence with  the  pus  cells  which  is  especially  characteristic 
of  gonococci. 

A  cover-glass  is  besmeared  with  a  drop  of  the  sus- 
pected pus,  covered  with  another  glass,  separated,  dried 
in  the  air,  and  passed  three  times  through  the  flame  as 
in  the  preparation  of  glasses  for  the  detection  of  the  tuber- 


Il8  A    CLINICAL    MANUAL. 

cle  bacillus.  They  are  stained  quickly  with  all  the  basic 
aniline  colors  ;  gentian  violet,  methyl  violet,  fuchsin,  and 
especially  well  with  an  aqueous  solution  of  methylene  blue. 
When  stained  they  are  rinsed  in  water,  dried,  and 
mounted.  An  exceedingly  good  double  stain  is  obtained 
by  using  Czenzynski's  solution. 

Methylene  blue  concentrated  aqueous  solution 40 

One-half  per  cent,  solution  of  eosin  in  70  fo  alcohol. .  .20 
Distilled  water 40 

The  cover-glasses  are  stained  for  five  minutes  in  this 
solution  heated,  rinsed  in  water,  dried  with  filtering 
paper,  and  mounted  in  Canada  balsam.  The  gonococci 
and  nuclei  are  stained  blue  while  the  cell-body  is  light 
red.     (Figure  32.)^ 

3.  Pleurisy. — Recent  investigations^  on  the  bacteri- 
ological aetiology  of  pleurisy  have  cleared  away  much  of 
the  doubt  and  uncertainty  involving  this  subject,  and 
have  furnished  valuable  hints  as  to  its  prognosis  and 
treatment.  Cases  of  pleurisy  are  commonly  divided  into 
two  classes,  according  to  the  character  of  the  exudate. 

A.  Serous  or  sero-fibrinous  pleurisy. 

B.  Purulent  pleurisy,  or  empyema. 

1.  The  serous  exudates  do  not,  as  a  rule,  contain  bac- 
teria. Many  of  them,  judged  by  the  history  of  the  case, 
by  lesions  elsewhere,  or  by  the  course  of  the  disease,  are 
probably  tubercular.  A  very  considerable  number,  how- 
ever, are  not  tubercular  in  origin,  and  in  many  of  these 
cases  the  prognosis  is  very  favorable. 

2.  The  purulent  exudates,  as  a  rule,  contain  bacteria. 
The    pneumococcus,    the    streptococcus    pyogenes,    the 

^  For  illustration  see  end  of  volume. 

^  Prudden,  "A  Study  on  the  Etiology  of  Exudative  Pleuritis," 
JVew  York  Medical  jfournal^  June  24,  1893. 


PATHOGENIC  MICRO-ORGANISMS.  II9 

bacillus  tuberculosis,  and  the  staphylococcus  pyogenes, 
either  alone  or  in  various  combinations,  are  the  bacteria 
commonly  found.  Of  these,  the  streptococcus  pyogenes 
and  the  pneumococcus  are  most  often  observed,  the 
streptococcus  pyogenes  being  usually  found  in  cases  of 
simple  empyema  and  the  pneumococcus  most  commonly 
in  cases  of  meta-pneumonic  empyema.  In  putrid  puru- 
lent exudates,  various  forms  of  saprophytic  bacteria  have 
been  found  either  alone  or  associated  with  the  ordinary 
pyogenic  germs. 

As  the  mortality  in  cases  of  empyema  due  to  the 
streptococcus  pyogenes  is  much  higher  than  in  those 
due  to  the  pneumococcus,  it  is  of  value  for  prognosis 
and  for  the  purpose  of  determining  suitable  operative 
procedure  to  subject  a  small  portion  of  the  exudate  to 
microscopical  examination  to  ascertain  its  bacteriological 
character. 

While  it  is  claimed  by  some  investigators  that  empyema  due  to  the 
pneumococcus  may  yield  to  aspiration,  and  the  empyema  associated 
with    the    streptococcus 


pyogenes  requires  opera- 


•••u 


tive  procedure,    aspira-  JT  *^g«****^      /   *•*        Jg  \    . 

tion  being  insufficient,  it  ••  ••       ^-i*       !     •mm* 

at  least  seems  certain 
that  the  question  of 
operative    procedure   is 


""" "  "■'  '■  r 


cases  associated  with  the  J                     i   i          s           ^m      * 

Streptococcus     than    in  **       *•••»,      •••%•• 

those  in  which  the  pneu- 
mococcus   or   staphylo-  FIG.  33.— streptococci  (after 
coccus  alone  is  found.  delafield  and  prudden). 

3.  To  determine  then  the  character  of  an  empyema,  a 
test-puncture  with  a  hypodermatic  syringe  should  be 
made.     A  little  of  the  pus  is  dropped  on  a  cover-glass, 


I20 


A    CLINICAL   MANUAL. 


which  is  covered  with  another  glass  and  treated  in  the 
usual  manner. 

4.  The  streptococci  are  spherical  cocci,  in  diameter 
about  one  fourth  the  length  of  the  tubercle  bacillus, 
arranged  in  chains  resembling  strings  of  beads  (Fig.  2>2>-) 
They  are  readily  stained  with  all  the  aniline  dyes,  and 
especially  well  with  Loffler's  alkaline  methylene-blue 
solution. 

Concentrated  alcoholic  solution  of  methylene  blue . .    30 
Solution  of  caustic  potash  i :  10,000 100 

The  cover-glass  is  placed  in  this  solution  for  a  minute 
or  two,  washed  in  water,  dried,  and  mounted  (Fig.  t,2>)- 

5.  The  pneumococci  are  lance-shaped  short  rods,  often 
resembling  micrococci,  and  appear  generally  in  pairs  or 
chains  of  four,  enclosed  in  a  capsule  (Fig.  34).     When 

stained  as  Welch  recom- 
mends, the  capsules  are 
distinctly  shown.  Glacial 
acetic  acid  is  dropped 
ujpon  the  cover-glass  and 
after  a  few  seconds  is 
allowed  to  run  off,  not 
washed  off  with  water  ; 
anilin  -  gentian  -  violet 
solution  ^  is  now  poured 
upon  it,  successive  por- 
tions   being    applied   for 


FIG.    34. — PNEUMOCOCCI     FROM   A 
CASE  OF  EMPYEMA. 


^5  c.c.  aniline  oil  are  added  to  100  c.c.  of  distilled  water,  shaken 
for  some  time  and  then  filtered  through  moistened  filtering  paper. 
The  filtrate  should  be  perfectly  clear,  should  contain  no  drops  of  oil, 
and  should  not  become  opaque  when  shaken.  Otherwise  it  must  be 
refiltered.  To  100  c.c.  of  the  filtrate  add  10  c.c.  of  absolute  alcohol 
and  II  c.c.  of  the  concentrated  alcoholic  solution  of  gentian- violet. 


PATHOGENIC  MICRO-ORGANISMS,  12  1 

4-5  minutes  until  the  acetic  acid  is  displaced.  It  is  then 
rinsed  in  a  2-per-cent.  solution  of  salt  (NaCl),  mounted 
and  examined  in  this  solution  of  salt  (Fig.  34). 

4.  Diphtheria. — The  Use  of  Bacterial  Cultures 
FOR  the  Differential  Diagnosis  between  True 
Diphtheria  and  other  Pseudo-Membranous  In- 
flammations. 

It  may  be  considered  as  fully  proven  that  true  diph- 
theria depends  upon  the  bacilli  first  described  by  Klebs 
and  Loffler  and  that  those  pseudo-membranes  and  exu- 
dates in  which  the  diphtheria  bacilli  are  absent  and  only 
various  forms  of  cocci  present  are  not  the  lesions  of  true 
diphtheria,  but  of  an  entirely  different  disease, 

I.  The  Diphtheria  Bacilli, — They   are  straight  or 
slightly  curved  rods  nearly  as   long   and   often  twice  as 
broad  as  the  tubercle  bacilli.     Sometimes  they  are  of  the 
same  width  throughout  their  whole 
length,  while  at   other   times  they 
are   pointed  or   clubbed   at  their 
ends  (Fig.  35),     Though  the  dif- 
ferent bacilli  differ  greatly  in  cul- 
tures  taken  from  different  cases,  j^ 
yet    they    all    have    certain    class 
characteristics  :    when    examined 
on   a  cover-glass  they   are  found 

,  .  .  ,     ,  FIG.     35. — PURE    CULTURE 

singly    or    m   pairs    and   have  no 

°  -^  ^  diphtheria       bacilli 

spores  ;  injected  into  guinea-pigs    prqm  serum   culture 
they    cause  death    within    a    few    from  throat,    x  2,000 
days,  and  when   inoculated  upon    diam. 
the   mucous   membrane    of  the  trachea  produce  a  true 
pseudo-membrane.     The  bacilli  grow  best   at  the  body 
temperature,   but   thrive  well   between   90°  and   100°  F. 
The  best   medium  for  their  growth  is  solidified   blood 
serum,  especially  that  prepared  after  Loffler's  formula  (3 


122  A    CLINICAL   MANUAL. 

parts  blood  serum,  one  part  nutrient  bouillon,  to  which 
i-per-cent  glucose  has  been  added).  The  bacilli  usually 
grow  well  on  alkaline  nutrient  agar,  especially  with  the 
addition  of  6  per  cent,  of  glycerine.  The  best  staining 
fluid  is  Loffler's  methyl-blue  solution  : 

Saturated  alcoholic  solution  of  methyl  blue  ....  30  parts 
Aqueous  solution  potassium  hydrate  1:10,000..  .70     " 

Stained  with  this  fluid  the  bacilli  usually  present  a 
very  characteristic  appearance.  Different  portions  of 
the  bodies  of  the  bacilli  stain  unequally,  and  the  ends 
are  usually  more  darkly  stained  than  the  bodies.  In  some 
cases  the  whole  bacillus  is  equally  stained. 

2.  Pseudo-Diphtheria  Bacilli. — This  name  has 
been  given  to  two  different  kinds  of  bacteria,  neither  of 
which  has  any  connection  with  the  disease  pseudo-diph- 
theria. The  first  variety  is  a  bacillus  which  is  in  every 
way  similar  to  the  diphtheria  bacillus,  except  that  when 
injected  subcutaneously  in  guinea-pigs  it  does  not  cause 
death.  This  bacillus  is  now  believed  to  be  the  true 
diphtheria  bacillus  which  has  lost  its  virulence.  The 
second  variety  is  a  bacillus  which  is  smaller  than  the 
Loffler  bacillus,  stains  more  evenly  with  the  methyl  blue, 
and  belongs  apparently  to  a  different  kind  of  bacteria. 

3.  The  Streptococci  and  other  Cocci  Found  in 
THE  Exudates  and  Pseudo-Membranes. — These  ap- 
pear to  be  the  same  as  those  usually  present  in  healthy 
throats.  They  are  minute  spheres  averaging  about  one 
seventh  the  diameter  of  a  red  blood-cell.  When  ex- 
amined on  a  cover-glass  the  cocci  are  found  to  be 
arranged  in  longer  or  shorter  chains,  as  diplococci,  and 
as  staphylococci.     All  forms  grow  readily  on  the  usual 


PATHOGENIC  MICRO-ORGANISM S.  123 

media   and  thrive   best   at  a  body   temperature.     They 
stain  readily  by  the  usual  dyes. 

4.  The  Practical  Value  of  Cultures. — Recent  investigations 
have  brought  out  the  great  importance  of  determining  the  presence  or 
absence  of  the  diphtheria  bacillus  in  the  exudate  of  an  inflamed  throat, 
for  it  has  been  found  that  a  considerable  proportion  of  inflamma- 
tions of  the  throat  commonly  considered  as  diphtheria  are  not  such, 
vi^hile  many  believed  during  the  first  days  or  even  throughout  the 
whole  disease  to  be  only  benign  in  character  are  found  to  be  true 
diphtheria. 

The  differential  diagnosis,  often  so  difficult  clinically,  is  readily 
made  with  cultures  within  twelve  hours.  The  cultures  should  be 
made  as  early  in  the  disease  as  possible,  not  only  for  the  importance 
of  quickly  recognizing  those  cases  which  are  true  diphtheria  so  that 
we  may  prevent  the  spreading  of  the  disease,  but  also  because  in  the 
milder  cases  of  true  diphtheria  the  bacilli  themselves  may  disappear 
from  the  throat  after  four  or  five  days.  Cultures  are  also  of  value  in 
convalescence,  to  determine  when  the  patient  ceases  to  be  a  danger 
to  others. 

5.  The  Methods  Used  to  Determine  the  Pres- 
ence OF  the  Bacilli  in  the  Throat. — The  attempt 
has  been  made  to  directly  smear  some  of  the  exudate 
from  the  throat  on  a  sHde,  dry  it,  stain  with  methyl  blue, 
and  examine.  In  a  certain  number  of  cases,  the  bacilli 
are  so  abundant  and  so  typical  that  a  quick  diagnosis 
can  thus  be  obtained,  but  there  are  many  others  in  which 
it  is  impossible  to  make  a  diagnosis  in  this  way.  The 
slower  but  sure  method  by  cultures  has  therefore  been 
adopted  by  all  investigators,  and  is  employed  either  alone 
or  in  addition  to  the  direct  microscopical  examination  of 
the  exudate. 

To  obtain  a  culture,  the  best  materials  are  a  tube  con- 
taining sterile,  slanted,  solidified  blood-serum,  and  a  steel 
rod  or  stick  armed  with  a  sterile  cotton  swab,  which  is 


124  A    CLINICAL   MANUAL. 

kept  in  a  second  tube.  The  patient  should  be  placed  in 
the  best  light  possible  and  properly  held.  In  cases  where 
it  is  easy  to  get  a  good  view  of  the  throat,  rub  the  cotton 
swab  gently  but  freely  against  any  visible  exudate.  In 
other  cases,  including  those  in  which  the  exudate  is  con- 
fined to  the  larynx,  open  the  mouth,  pass  the  swab  back 
till  it  reaches  the  pharynx,  and  then  rub  it  freely  against 
the  mu(?ous  membrane  of  the  pharynx  or  tonsils.  With- 
out laying  the  swab  down,  withdraw  the  cotton  plug  from 
the  culture  tube,  insert  the  swab  and  rub  that  portion  of 
it  which  has  touched  the  exudate  gently  back  and  forth 
along  the  surface  of  the  blood-serum.  Then  replace  the 
swab  in  its  own  tube,  and  plug  both  tubes  with  the  cot- 
ton. The  inoculated  tube  is  now  to  be  kept  for  ten  to 
twelve  hours  at  a  temperature  between  90°  and  100°  F. 
It  is  then  ready  for  examination.  On  inspection,  the 
blood-serum  surface  will  be  seen  to  be  dotted  with  very 
numerous,  just  visible,  translucent  colonies.  At  this 
time  no  diagnosis  can  be  made  from  simple  inspection. 
A  clean  cover-glass  with  a  tiny  drop  of  water  having 
been  prepared,  a  platinum  wire  is  inserted  in  the  blood- 
serum  tube  and  a  sweep  made  of  a  large  number  of 
colonies.  The  bacteria  adherent  to  the  wire  are  washed 
off  in  the  drop  on  the  cover-glass  and  smeared  over  its 
surface.  After  drying,  it  is  carried  quickly  through  the 
Bunsen  flame  three  times,  then  covered  with  a  few  drops 
of  Loffler's  solution  of  alkaline  methyl  blue,  and  left  for 
five  minutes.  The  cover-glass  is  then  rinsed  off  in  clean 
water,  and  either  examined  in  water  on  the  slide  or  dried 
and  mounted  in  balsam. 

In  the  great  majority  of  cases,  one  of  two  pictures  will 
be  seen  with  the  oil-immersion  lens  :  either  an  enormous 
number  of  one  of  the  characteristic  forms  of  the  diph- 


PATHOGENIC  MICRO-ORGANISMS. 


125 


theria  bacilli,  with  or  without  a  moderate  number  of  diplo- 
or  streptococci  (Fig.  35),  or  a  pure  culture  of  cocci  mostly 
in  pairs  and  chains.  In  a  few  there  will  be  an  approxi- 
mately even  mixture  of  Loffler  bacilli  and  cocci  (Fig.  36), 
and  in  some  with  the  cocci  there  will  be  a  moderate  num- 
ber of  bacilli  in  chains  or  scattered,  some  resembling  a 
little,  and  others  not  at  all,  the  Loffler  bacilli  (Fig.  37). 


FIG.  36. — MIXED    CULTURE   OF 
cocci  AND  DIPHTHERIA  BACILLI. 


FIG.  37. — CULTURE  OF  VARIOUS 
FORMS  OF  cocci,  AND  A  FEW  NON- 
PATHOGENIC BACILLI. 


The  question  will  be  asked,  how  much  knowledge  of  bacteriology 
is  it  necessary  for  a  physician  to  have  in  order  to  make  the  cultures 
and  the  microscopical  examinations  ?  Any  one  who  is  accustomed  to 
examine  sputa  for  the  tubercle  bacillus,  and  is  able  to  clearly  tell  a 
bacillus  from  a  coccus,  can  easily  make  a  positive  diagnosis  in  nine 
tenths  of  the  cases,  if  he  carefully  follows  the  instructions  here  given, 
and  is  supplied  with  a  good  oil-immersion  lens.  It  will  help  him 
greatly  in  his  first  case  if  he  has  previously  studied  cover-glass 
preparations  of  the  stained  diphtheria  bacilli. 

The  diagnosis  of  true  diphtheria  is  certain  in  those  cases  in  which 
a  great  number  of  bacilli  resembling  those  of  diphtheria  are  present 
in  the  cultures  (Fig.  36),  while  in  those  in  which  no  bacilli  but  only 
cocci  are  found,  the  diagnosis  of  false  diphtheria  is  equally  sure,  if 
the  culture  was  made  during  the  first  days  of  the  disease  and  no  anti- 
septic had  just  previously  been  applied.  Those  in  which,  among 
numerous  kinds  of  cocci,  there  are  a  few  bacilli  which  look  somewhat 


126  A    CLINICAL  MANUAL, 

like  the  diphtheria  bacilli  and  yet  are  not  characteristic,  are  very 
difficult  to  diagnosticate  (Fig.  37).  Those  who  have  had  little  ex- 
perience had  better  simply  consider  these  from  the  bacterial  stand- 
point as  suspicious  cases,  and  give  no  positive  opinion. 

The  absence  of  diphtheria  bacilli  in  cultures  made  from  throats  in 
which  the  disease  was  confined  to  the  larynx  does  not  absolutely  ex- 
clude the  diagnosis  of  true  diphtheria. 

6.  A  Ready  Method  for  Preparing  the  Materials  and 
Apparatus  Needed  for  Diphtheria  Cultures. — Blood-serum  is 
obtained  by  catching  the  blood  directly  from  a  slaughtered  sheep  or 
steer  into  large  covered,  clean  glass  jars  or  pails.  The  blood  is 
allowed  to  clot  and  then  kept  on  ice  for  twenty-four  hours.  The 
serum  is  then  syphoned  off  by  a  rubber  tube  and  mixed  with  one  third 
its  bvilk  of  the  bouillon.  The  bouillon  is  made  by  soaking  one  pound 
of  raw  chopped  beef  in  one  litre  of  water  for  twelve  hours  in  a  cool 
place.  This  is  then  strained  through  cheese-cloth  and  to  it  is  added 
one-per-cent.  peptone,  one-per-cent.  glucose,  and  one-half-per-cent. 
salt.  The  whole  is  boiled  for  one  half  hour,  filtered,  and  is  then  ready 
to  be  added  to  the  serum.  The  necessary  number  of  short  wide  test- 
tubes,  having  been  previously  plugged  with  cotton,  and  if  possible 
sterilized  by  dry  heat,  are  now  filled  to  the  height  of  one  inch  with  the 
serum  mixture  and  put  in  a  slanting  position  on  a  serum  coagulator,  or 
when  this  is  not  at  hand  in  the  inner  vessel  of  a  double  boiler.  This 
is  now  kept  just  below  the  boiling  temperature  for  an  hour.  The 
tubes  are  then  allowed  to  cool,  and  then  heated  for  the  same  length 
of  time  the  following  day.  The  serum  is  thus  firm  and  sterile. 
The  tubes  are  stored  in  a  tin  box,  and  remain  for  months  ready  for 
use.  The  swabs  are  most  neatly  made  from  6-inch  pieces  of  steel 
wire.  One  end  is  roughened  and  wound  tightly  with  a  very  little 
absorbent  cotton.  This  placed  in  a  tube  is  then  sterilized.  A  per- 
fectly satisfactory  incubator  can  be  made  from  a  double  boiler.  The 
upper  vessel  is  weighted  with  lead  or  sand  sufficient  to  hold  it  down 
when  the  lower  vessel  is  full  of  water.  The  tin  cover  is  replaced  by 
a  board  which  has  been  perforated  at  its  centre  for  the  insertion  of  a 
thermometer.  The  whole  can  be  covered  with  asbestos.  A  Bunsen 
burner,  the  outer  tube  of  which  has  been  removed,  makes  a  satisfac- 
tory burner.  Even  without  a  regulator,  the  gas  can  be  so  adjusted 
that  the  temperature  of  the  incubator  will  not  vary  too  greatly  from 
98°  F.  for  use. 


PATHOGEmC  MICRO.ORGAIVISMS. 


127 


5.  Amceba  Coll — Osier  describes  the  amoeba 
unicellular  protoplasmic  motile  organism  from 
20  yw  diameter  (2-3  times  the 
size  of  a  red  blood-cell), 
consisting  of  a  clear  outer 
zone,  ectosarc,  and  a  granu- 
lar inner  zone,  endosarc  con- 
taining a  nucleus  and  one  or 
more  vacuoles  (Fig.  38). 


as  a 
10   to 


FIG.  38. — AMGEBA  COLI   (AFTER 
DELAFIELD    AND    PRUDDEN). 


They  are  present  constantly  in 
the  stools,  in  the  intestines,  and  in 
the  complicating  liver  abscesses  in 
the  endemic  dysentery  of  Egypt, 
and  have  also  been  found  in  this 
country  in  a  number  of  cases  of 

dysentery  reported  by  Osier,  Councilman,  Lafleur,  Dock,  Musser,  and 
others.  The  amoebae  are  more  numerous  in  the  small  gelatinous 
masses  often  contained  in  the  faeces,  but  their  numbers  vary  in  differ- 
ent cases  and  even  in  the  same  case  at  different  times,  although  they 
are  usually  proportional  to  the  severity  of  the  disease.  Their  appear- 
ance differs  according  to  their  state  ;  activity  or  inactivity.  When 
inactive  they  are  round,  slightly  oblong,  more  refractive  than  other 
cells  found  in  the  faeces,  and  contain  vacuoles  of  varying  size.  The 
vacuoles  are  clear  and  their  contents  paler  than  the  surrounding  sub- 
stance. When  active  they  have  a  characteristic  appearance  due  to 
a  double  movement  :  progressive,  and  one  limited  to  the  protrusion 
and  retraction  of  pseudopodia. 


In  seeking  the  amoeba,  Councilman  advises  that  atten- 
tion should  be  paid  to  the  following  points. 

1.  The  stools  are  to  be  passed  into  a  warm  bed-pan 
and  kept  at  a  temperature  of  30°  to  35°  C.  (86°-93°  F.) 
until  an  examination  is  made. 

2.  The  examination  should  be  made  as  soon  as  possible, 
before  the  stools  become  acid. 


128 


A  Clinical  manual. 


3.  The  small  gelatinous  masses,  which  feoiitaia  amoebae 
in  greatest  abundance^  should  be  carefully  examined. 

A  magnifying  power  of  400  is  most  suitable,  though 
they  may  be  found  with  a  magnifying  power  of  too. 
diameters.  Some  form  of  warm  stage  is  essential  if  the 
observation  is  to  be  continued. 

This  form  of  dysentery  is  characterized  by  a  variable  onset,  irregu- 
lar course,  frequent  intermissions  and  exacerbations,  and  by  a  ten- 
dency to  chronicity.  The  main  characteristic  of  the  stools  is  their 
fluidity.  They  may  or  may  not  at  first  contain  blood,  but  later  both 
blood  and  mucus  are  almost  always  present.  From  six  to  twelve 
yellowish-gray  stools  are  passed  daily  for  weeks.  Abscess  of  the 
liver  is  a  frequent  and  serious  complication.  The  stools  in  all  cases 
of  prolonged  diarrhoea  should  be  carefully  examined  for  amoebae. 

6.  Plasmodium  Malari^e. — The  fact  that  malaria  is 
due  to  the  presence  of  a  parasite  in  the  blood  was  first 
definitely  determined  by  Laveran.  His  discovery  has 
been  confirmed  by  Italian  observers  and  by  numerous 

workers  in  the 
United  States. 
These  micro-or- 
ganisms are  pro- 
tozoa, belong  to 
the  division 
known  as  hsema- 
tozoa,  and  are 
found  in  the  red 
blood-cells. 

The  following 
are  the  forms 
representing 
stages  in  their  life  history  as  described  by  American 
observers.     The  parasite,  however,  assumes  a  variety  of 


FIG.    39. — PLASMODIUM   MALARIA. 


PATHOGENIC  MICRO-ORGANISMS.  1 29 

forms  in  cases  in   the  same  locality  and  shows  marked 
variations  in  different  countries. 

1.  An  unpigmented  hyaline  body  within  the  red  blood- 
cells.     (Fig.  39.) 

2.  A  pigmented  amoeboid  body  within  the  red  blood- 
cells.     (Fig.  39.) 

3.  A  segmenting  body  more  or  less  perfect  which 
breaks  up  into  a  varying  number  of  small  spheroids 
(spores).     (Fig.  39.) 

4.  Crescents  containing  pigment.     (Fig.  39.) 

5.  Flagellate  organisms  which  develop  from  the  inter- 
cellular pigmented  forms  or  from  ovoid  bodies  which 
are  altered  crescents. 

6.  Free  flagella. 

Golgi  has  described  two  varieties  of  this  parasite  :  one,  in  which 
the  pigment  granules  are  finer  and  the  spheroids  more  numerous,  15- 
20,  he  associates  with  the  tertian  type  of  malaria  ;  and  the  other,  in 
which  the  pigment  granules  are  coarser  and  the  spheroids  less  numer- 
ous, 6-12,  with  the  quartan  type.  The  other  types  of  malaria,  he 
claims,  are  simply  modifications  or  combinations  of  these  two. 

The  blood  for  examination  should  be  obtained  at  the 
height  of  the  chill,  in  the  manner  described  under  blood  ex- 
aminations (page  loi).  It  is  readily  stained  by  gently  heat- 
ingforiotoi5minutesinCzenzynski'ssolution(page  103). 
The  Plasmodia  are  stained  blue,  the  red  blood-cells  and 
the  bodies  of  the  leucocytes  a  light  red,  their  nuclei  a 
deep  blue,  and  the  eosinophilic  granules  of  the  leucocytes 
a  deed  red.  As  the  plasmodia  rapidly  disappear  after  the 
administration  of  quinine,  the  preparations  of  blood 
should  be  obtained  before  quinine  is  administered. 


APPENDIX  I. 


REAGENTS  NECESSARY. 

(A)  in  the  examination  of  the  urine  : 

1  Concentrated  yellow  nitric  acid. 

2  "  acetic  acid. 

3  "  hydrochloric  acid. 

4  "  sulphuric  acid. 

5  Caustic  soda  (liq.   sodse),    a  solution  containing  15  per  cent,  of 

sodium  hydrate, 

6  Saturated  solution  of  salt  (Na  CI). 

7  Calx    chlorata,    a   half-saturated   solution  ;    made   by   diluting   a 

saturated  solution  of  chlorinated  lime  with  an  equal  volume  of 
water.     This  solution  should  be  renewed  from  time  to  time. 

8  Chloride  of  iron  (liq.  ferri  sesquichloridi).     It  should  have  an  acid 

reaction,  but  must  be  free  from  acid  and  should  alv^ays  give  a 
precipitate  (iron  hydroxide)  upon  the  addition  of  a  drop  of 
aqua  ammonia. 

9  Ferrocyanide  of  potassium,  lo-per-cent.  solution. 

10  Sulphate  of  copper,  lO-per-cent,  solution. 

11  Fehling's  solutions. 

12  Aqua  ammonise,  10  per  cent.  NH3. 

13  Lugol's   solution,    an    aqueous   solution    of   iodine    in    iodide    of 

potassium. 

14  Millon's  reagent.     Dissolve  one  part  of  mercury  in  an  equal  part 

of  nitric  acid  and  dilute  with  twice  its  bulk  of  water,  then 
separate,  after  some  hours,  by  filtration,  the  reagent  from  the 
precipitate. 

15  Double  solution  of  iodide  of  potassium  and  biniodide  of  mercury. 

The  biniodide  of  mercury  is  dissolved  in  a  warm  solution  of 
iodide  of  potassium  to  saturation  and  diluted  with  several 
volumes  of  water. 

131 


132  APPENDIX  I. 

16  Nitrate  of  silver,  5-per-cent.  solution.     Keep  in  dark  bottle. 

17  Alcohol,  90  per  cent. 

18  Chloroform. 

19  Ether. 

Other  solutions  as  needed. 

(B)  In  the  examination  of  the  stomach  contents  : 

1  Iodide  of  potassium  in  keratin-coated  pills. 

2  Salol. 

3  Methyl-aniline. 

4  Congo  paper. 

5  Trop^olin  OO. 

6  Vanilla. 

7  Phloroglucin. 

8  Resorcin. 

9  Carbolic  acid  (liquid). 

10  Carmine  fibrin. 

11  Egg  albumin. 

(C)  In  the  examination  for  micro-organisms  : 

1  Cone,  alcohol  sol.  of  fuchsine. 

2  "  "  "     "  methylene  blue. 

3  "      aqueous  "     "  "  " 

4  One-half-per-cent.  sol.  of  eosin  in  70  per  cent,  alcohol. 

5  Solution  of  caustic  potash  (1:10,000). 

6  Czenzynski's  solution. 

7  Glacial  acetic  acid. 

(D)  In  the  examination  of  blood  : 

1  Solution  of  sodium  chloride  3  %. 

2  "         "  acetic  acid  .3-.  5  ^. 
Ehrlich's  solutions. 

Apparatus  necessary  : 
Test-tubes,  watch  glasses,  porcelain  dishes,  conical  glasses,  glass 
funnels,  glass  rods,  platinum  foil,  retort  stand,  water  bath,  iron 
tripod,  litmus  paper,  urinometer,  stomach  tube,  slides,  glasses, 
apparatus  for  examination  of  blood,  microscope  with  suitable 
objectives. 


APPENDIX  II. 

Metric  Weights  and  Measures  employed  in  this  book  with  their 
equivalents  in  grains,  or  minims  : 


Milligram 
Centigram 
Decigram 
Gram 


Micromillimetre  (/^)  = 

Millimetre  = 

Centimetre  = 

Decimetre  = 

Metre  = 

Cubic  millimetre  = 

Cubic  centimetre  (c.  c.)       =: 

Litre  (tooo  c.  c.)  = 

Fahrenheit   and    Centigrade    thermometric    scales    compared    and 
formulae  for  converting  the  registration  of  one  into  that  of  the  other  : 


Gram. 

Grains. 

.001 

= 

.01543 

.01 

= 

•1543 

.1 

= 

1-5432 

I. 

z:^ 

15-43235 

Metre. 

Inches. 

.000001 

= 

.00004 

.001 

= 

•03937 

.01 

=: 

.3937 

.1 

= 

3-937 

I. 

= 

39.37 

Cubic  inches. 

Minims. 

,00006 

= 

.01622 

.0610165 

^- 

16.22 

Quart. 

61. 

= 

.946 

Fahr. 

Cent, 

212° 

= 

100  ° 

160° 

= 

71.1° 

120  ° 

= 

48.9° 

100° 

-= 

37.8° 

80° 

= 

26.7° 

60° 

= 

15-6° 

32° 

= 

0.  ° 

0° 

= 

17.8° 

133 


134  APPENDIX  II. 

To  convert  Fahrenheit  scale  to  Centigrade  : 
r  -  5  (F  -  32) 
9 

To  convert  Centigrade  scale  to  Fahrenheit : 


FIG.   5. — PHENYL-GLUCOSAZON  (jAKSCh). 


A  few  needles  may  be  found  in  any  specimen  of  urine,  with   heaj^s 
of  yellow  amorphous  granules  and  brownish-red  scales. 


0..Q. 


c 


'^  'Or'*'- 


.©a 


^(#    ,^ 


Qo!:o^t^. 


FIG.   27. — STAINED  PREPARATION  OF  NORMAL  BLOOD. 


^ 


^h 


^Z" 


a 


%jf 


.#• 


f       f  j 


f 


FIG.    28. — AN/KMIC  HLOOD  STAINED  BY  EHRLICH'S  METHOD 
(AFIER  V.   LIMBECK). 

a,  mef^altK-ytes  ;  b,  leucocytes  (different  kinds)  ;    </,  poikilocyles 
e,  mycrocytes  ;  /,  normal  red  hlood  cells. 


^5-0  ^'^'^^   A« 


^  ^'^&    '"^ 


d 


t- 


s 


%z     r 


©1 


FIG.    29.    -  l.EUK.EMIC  BLOOD  STAINED  WITH  EOSIN  AND 
H^MOTOXYLON. 


FIG.    31.— TUBERCLE    BACILLI    FROM    SPUTUM. 


FIG.    32.— MICROCOCCI    GO.\ORRHfE/E 
(GONOCOCCI). 


INDEX. 


PAGE 

PAGE 

Absorption,  bands 

20 

Albuminuria,  physiological, 

7 

"            rate  of,  in  stom- 

''           renal 

8 

ach  .         . 

77 

' '           transitory 

8 

Acetic  acid  and  ferrocyanide 

Albumose    . 

17 

of  potassium  test 

II 

Alkaline  urine 

3 

Acetic  acid  and  sodium  chlo- 

Alkaloids in  urine 

53 

ride  test    .... 

12 

Almen's  test  for  blood  . 

22 

Acetic  acid  in   gastric   con- 

Ammonia, urate  of 

59 

tents         .... 

82 

' '          carbonate    of, 

in 

Acetone  in  urine  . 

42 

gastric  contents 

86 

Acid,  acetic 

82 

Ammoniacal  fermentation 

I 

"     butyric 

82 

Ammonio-magnesium    phos- 

"    carbolic 

52 

phate 

49 

,  58 

"     chrysophanic 

52 

Amoeba  coli 

127 

"     diacetic 

43 

Anaemia,  pernicious 

. 

106 

""    formic 

82 

"        secondary 

. 

105 

"     glycuronic  . 

42 

"     hippuric 

61 

Bacilli  {vide  micro-organisms) 

114 

"     hydrochloric 

79 

Bacterium  urese   . 

I 

"     lactic. 

82 

Basophilic  granules 

lOI 

"     salicylic 

52 

Bile,  in  fosces 

89 

"     succinic       .         . 

113 

"     in  gastric  contents 

85 

"     uric    .         .         .         . 

46 

"     in  urine 

23 

Acidity,  of  gastric  juice 

75 

"     tests  for 

24 

"         of  urine 

3 

Bilirubin  in  urine 

61 

Albumin,  estimation  of 

13 

Bismuth  test  for  sugar  . 

37 

"         in  exudates  . 

108 

Biuret  test    . 

19 

"         in  faeces 

89 

Blood,  examination  of . 

93 

"         in  transudates 

108 

"      in  faeces     . 

89 

"         in  urine 

7 

"      in  gastric  contents 

86 

"         separation  of 

15 

"      in  urine     . 

19 

,63 

"         tests  for 

9 

Blood-cells,    preparation 

of 

Albuminimeter     . 

15 

slides  of   . 

. 

lOI 

Albuminuria,  accidental 

8 

Blood-cells,  red    . 

63 

,  93 

135 


136 


INDEX. 


Blood-cells,  staining  of 

' '  white 

Bottger's  test 
Brandberg's  method 
Bromides  in  urine 
Butyric  acid  in  gastric 
tents 


Calcium  carbonate 
"  phosphate 
"        sulphate 

Calculi,  urinary    .          .  .69 

Carbolic  acid  in  urine  .  .52 
Carbol-iron    test    for    lactic 

acid           .         .         .  .82 

Carbonate  of  lime         .  .     60 

Carbonates  in  urine      .  .     49 

Carmine      fibrin      test  for 

pepsin       .         .         .  .84 

Casts,  urinary       .         .  .65 

Centigrade  scale  .         .  .133 

Charcot-Leyden  crystals  .     90 
Chlorate  of  potash  in  urine  .     50 

Chlorosis,  blood  in       .  .   105 

Cholesterin  crystals      .  90,  91 

Chrysophanic  acid        .  .52 

Ch)de  in  urine      .          ,  .44 

Concretions  in  faeces    .  ,     91 

Congo  test  .         .         .  .80 

Copaiva  balsam  in  urine  .     53 
Cover-glasses,      preparation 


PAGE 

102 

99 
37 
13 
51 

82 

60 

58,  90 

59 


of     .  .  .  .    lOI, 

Crystals  in  faeces 
' '        in  urine 
Cystin 

Cysts,  echinococcus 
' '      ovarian 


Dextrose  {vide  grape  sugar) 
Diacetic  acid 
Digestion,  gastric 
Diphtheria,  bacteria  in 
Donne's  test  for  pus 
Doremus'  ureometer 

Earthy  phosphates 
Echinococcus  cysts 


114 

89 

55 

60 

112 

109 

27 

43 

75 

121 

63 
45 

58 
112 


Egg-albumin  test  for  pepsin     85 

Ehrlich's  granules         .         .   loi 

"         staining     solutions 

103,  104 
Einhorn's  saccharometer       .     40 
"         stomach  bucket    .     77 
Electrolysis  in  urinary  sedi- 
mentation         .         .         .54 
Eosinophilic  cells         .         .   loi 
Epithelial  cells  in  urine        ,     63 
Esbach's  albuminimeter        .     15 
Ewald's  method  of  expression     76 
"       test-meal  .         .     76 

Exudates,  character  of  .   108 

"         in  pleurisy  ,         .118 

Faeces  .         .         .         .89 

Fahrenheit  scale  .         .  133 

Fat  in  urine  .  .        44,  61 

Fehling's  test  for  sugar         .     34 
Fermentation  test,  Einhorn's     39 
"    ^  "     Roberts'.     40 

Fibrin  iri  urine     .  .  .16 

Filaria  sanguinis  hominis      .     44 
Fluorescence  test  for  urobi- 
lin  .  .  .  .  .26 
Formic  acid  in  gastric  con- 
tents        .          .         .          .82 
Fungi  in  urine     .          .  i,  67 

Gabbet's  modification  .  .116 
Gall-stones  .         .         .  .91 
Gastric    contents,    examina- 
tion of      .          .          ,  .75 
Glycosuria,  persistent  .  .     28 
"           physiological  .     28 
"            transitory  .  .     28 
Glycuronic  acid   .         .  .42 
Gmelin's  test  for  bile   .  .     24 
Gonococcus,  the  .         .  .117 
Gowers'    haemoglobinometer     97 
Granular  casts      .         .  .65 
Grape  sugar  in  urine    .  .     27 
Gunzburg's  test    .         .  .81 

Haeniin  crystals   .         ,         ,22 
Haemoglobin  in  urine  .        19,  61 


INDEX. 


137 


Haemoglobin  in  stomach  con- 
tents .  .  .  .86 
Hsemoglobinometer.Gowers'  97 
Hcemometer,  v.  Fleischl's  .  97 
Heat  test  for  albumin  .  .  9 
"  "  "  blood  .  .  21 
Heintz's  method  for  uric  acid  47 
Heller's  test  for  albumin  .  10 
"  "  blood  .  21 
Hippuric  acid  .  .  .61 
Hofmeister's  test  for  peptone  18 
Huppert's  test  for  bile  .  25 
Hyaline  casts  .  .  .66 
Hydrobilirubin  .  .  .25 
Hydrochloric  acid,  tests  for, 

79,  80,  81 
Hydronephrosis  .  .  .111 


Hydrothionuria    . 
Hypobromite  method  . 

Indican  in  urine  . 
Indigo-carmine  test 
Intestinal  stones  . 
lodide-of-potassium  test 
Iodides  in  urine  . 
Iodine  test  for  bile 
Iron-chloride  test 

Jaffe's  test  for  indican 


47 

45 

26 
41 
91 

78 
51 
25 
82 

27 


Kidney,  table  of  diseases  of 

the  .         .  .         .        73,  74 

Klebs-Lofller  bacillus  .  .121 

Lactate  of  lime  .  .  .90 
Lactic  acid  in  gastric  contents  82 
Lactosuria  .         .         .28 

Legal's  test  for  acetone  .  42 
Leube's  table  of  diseases  of 

the  kidney        .         .        73,  74 
Leube's  test-meal  .         .     76 

Leucin  .  .  ,  .60 
Leucocytes  in  blood     .  ,     99 

"  in  urine      .         ,     62 

Leucocytosis,  pathological    .     99 
"  physiological  .     99 

Leukarmia  .         .         .    100,  106 


Lieben's  test  for  acetone 
Litten  centrifugal  machine 
Lymphocytes 

Magnesium  phosphate . 
Malarial  plasmodia 
Megalo-blasts 
Mercury  in  urine 
Metalbumin    {znde     pseudo 

mucin) 
Methaemoglobin  in  urine 
Metric  system 
Micrococcus,  gonorrhoeae 

"  ureae 

Microcytes  . 
Micro-organisms  . 


diph 
dysen 


43 
54 
99 

58 
128 

94 

50 

no 
20 

133 
117 

I 

94 

114 

121 


127 

117 

128 


theria 

Micro-organisms, 
tery  (amoebic)  , 

Micro-organisms,    in  gonor 
rhoea 

Micro-organisms,  in  malaria 
"  "  in  pleurisy  118 

in  tubercu- 
losis .... 

Micro-organisms,  in  urine,  67 

Millon's  reagent  . 

Moore's  test  for  sugar  . 

Mucin  in  urine     . 

Mucus  in  urine    . 

Murexide  test 


114 

117 
61 
28 
16 
62 
46 


Neutrophilic  granules  .  .   102 

Nitric  acid  test  for  albumin  .     10 
Nitro-prussic    soda   test   for 

acetone    .  .  .         .42 

Nucleo-albumin  (mucin)        .      16 
Nylander's  test  for  sugar       ,     37 


C>ligochromaemia 
Oligocythaemia     . 
Ovarian  cysts 
Oxalate  of  lime    . 
Oxyhaemoglobin  . 


•     95 
.     94 

.  109 

57,  90 
.     20 


l^athogenic  micro-organisms    114 


138 


INDEX. 


Salicylates  in  urine 

Salol  test 

Santonin  in  urine 

Spectral  test  for  urobilin 

Spectroscopic  examination 

Spermatozoa 

Sputum,  examination  of 

Staining  fluids      .  .    103,  104 

Staphylococcus  pyogenes      .   118 


PAGE 

108 

77 
83 
18 

85 


Pathological  fluids 
Penzoldt's  test 

Pepsin  in  gastric  secretion  . 
Peptone  in  urine  . 
Pettenkofer's  test 
Pbenyl-hydrazin      test      for 

sugar        .         .         .  •     39 

Phloroglucin  test           .  .81 

Phosphates,  in  faeces    .  .     90 

"             in  urine    .  49,  58 

Plasmodium  malarise    .  .128 

Pleurisy        .          .          .  .118 

Pneumococcus      .         .  .118 

Poikilocytosis       .         .  .94 
Propeptone     (albumose)     in 

urine         .          .          .  .17 
Prudden,    bacillus    tubercu- 
losis in  urine     .         .  .117 
Prudden,  pleuritic  exudate  .   118 
Pseudo-diphtheria  bacillus  .   122 
"      leukaemia          .  .   107 
"      mucin       .         .  .110 
Pus  (leucocytes)  in  urine  .     62 

Reaction  of  blood         .  .     93 

"        "  exudates   .  .  108 

"  faeces         .  .     89 

"        "  gastric  juice  .     75 

"        "  transudates  .   108 

"        "  urine         .  .       3 

Reagents     .         .         .  .131 

Renal  albuminuria       .  .       8 

"      casts.         .         .  .65 

Rennet  ferment   .         .  .85 

Resorcin  test        .         .  .81 

Roberts'  fermentation  test  .     40 

Rosenbach's  test .         .  .24 


52 
78 
3.  53 
25 
20 
67 
114 


Starch,  digestion  of      .  .75 

Sterilized  blood  serum  .  .   126 

"        tubes     .         .  .   126 

Stokois'  test  for  bile     .  .     25 

Stomach  contents          .  .     75 

Streptococcus  pyogenes  .   118 

Succinic  acid        .          .  .113 

Sugar  in  urine      .          .  .27 

Sulphates  in  urine        .  -49 

Sulphuretted     hydrogen  in 

urine        .         .          .  -47 

Tannin  in  urine  .  .  .52 
Test-meals  .  .  .  .76 
Test-tubes  sterilized  .  .126 
Thoma-Zeiss  haemacytometer  95 
Transudates  .  .  .108 
Triple  phosphates  in  faeces  .  8g 
"  "  in  urine    .     58 

Trommer's  test  for  sugar      .     29 
Tropseolin  test     .         .         .80 
Tubercle  bacillus  in  sputum  114 
"  "        in  urine    .   117 

Tyrosin        .         .         .         .60 


Urates,  casts  of 
"       in  urine 

Urea  in  urine 

Uric  acid     . 

Urine,  the   . 
"       calculi 


.     66 

.     55 

.     44 

46,  55 

I 

69 


changes  after  excre- 
tion in  .  .  .1 
color  of  .  .  .2 
composition,  quanti- 
tative, of  .  .6 
constituents,  accidental  50 
deposits  in  .  .53 
quantity  of  .  .  2 
reaction  of  .  .  3 
sediment,   organized, 

of  ...     62 

sediment,      unorgan- 
ized, of  .         .55 
selection  of  a  speci- 
men of  .         .         .       7 


INDEX. 


139 


PAGE 

Urine,  substances,  inorganic, 

in  ...     47 

"       substances,  organic,  in       7 

Urobilin  in  faeces  .         .     89 

"         in  urine  .         .25 

Vierordt's  table    .         .         .87 
Von  Fleischl's  haemometer  .     97 


PAGE 

Waxy  casts  .         .         .66 

Welch,  stain  of  .  .  .118 
White  blood-cells  (leucocytes)  99 
Worm-Miiller's  test  for  sugar     36 


Ziehl-Neelsen  stain 


115 


NOTES. 


NOTES. 


NOTES. 


NOTES. 


NOTES. 


NOTES. 


NOTES. 


NOTES. 


NOTES. 


NOTES. 


NOTES. 


NOTES. 


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A  clinical  manual  ••» 


